Provider Demographics
NPI:1134468267
Name:SHUMWAY, SAM FAULKNER (PA)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:FAULKNER
Last Name:SHUMWAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1533 E WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2935
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:602-569-3887
Practice Address - Street 1:7734 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7816
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:602-569-3887
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2019-08-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ5284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863734Medicaid