Provider Demographics
NPI:1225107089
Name:COLLINS, SAMUEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:COLLINS
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 1:1510 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4523
Mailing Address - Country:US
Mailing Address - Phone:541-231-2591
Mailing Address - Fax:
Practice Address - Street 1:203 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:TONASKET
Practice Address - State:WA
Practice Address - Zip Code:98855-8803
Practice Address - Country:US
Practice Address - Phone:509-486-3144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60475541363AS0400X
FLPA9103177363AS0400X
ORPA00601363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292272000Medicaid
WA2037524Medicaid
WA2037524Medicaid