Provider Demographics
NPI:1144748831
Name:MILLETT, SAMUEL KINGSBURY (PA-S)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KINGSBURY
Last Name:MILLETT
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 11TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 S HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6923
Practice Address - Country:US
Practice Address - Phone:206-616-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-02
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114327363A00000X
MT95698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant