Provider Demographics
NPI:1003138181
Name:KIPPENBERGER, SAMUEL M (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:KIPPENBERGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RIDGEWOOD RD
Mailing Address - Street 2:ESNE/SPRINGFIELD HOSPITAL EMERGENCY DEPARTMENT
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-3050
Mailing Address - Country:US
Mailing Address - Phone:802-885-7540
Mailing Address - Fax:
Practice Address - Street 1:25 RIDGEWOOD RD
Practice Address - Street 2:ESNE/SPRINGFIELD HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3050
Practice Address - Country:US
Practice Address - Phone:802-885-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30337990Medicaid
VT9000464Medicaid
NH0014873Medicare PIN