MEDICARE: SAMUEL BAUMGUARDNER II PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA01266	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	483780YPVD	OTHER	TX	TX MEDICARE

General Provider Information

NPI Number	:	1295109510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL BAUMGUARDNER II PA-C

Provider Business Mailing Address
First Line	:	4214 ANDREWS HWY STE 240
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79703-4817
Country	:	US
Telephone Number	:	432-686-6605
Fax Number	:	432-682-2284

Provider Business Practice Location Address
First Line	:	400 ROSALIND REDFERN GROVER PKWY STE 200
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79701-5852
Country	:	US
Telephone Number	:	432-221-2107
Fax Number	:	432-221-5218

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/24/2015
Last Update Date	:	08/06/2020

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