=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558161695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ADAM BLOXHAM PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2025
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2286 MALAGA AVE
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84765-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-215-3444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2286 MALAGA AVE
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84765-5485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-215-3444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 14206396-1206
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------