Healthcare Provider Details

I. General information

NPI: 1861283558
Provider Name (Legal Business Name): SAMANTHA MIYUKI SUEOKA PA-C
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 S FOOTHILL DR
SALT LAKE CITY UT
84109-4000
US

IV. Provider business mailing address

326 E SHAMROCK DR
MURRAY UT
84107-3981
US

V. Phone/Fax

Practice location:
  • Phone: 801-486-3021
  • Fax: 801-485-6339
Mailing address:
  • Phone: 801-808-2814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14291199-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: