Provider Demographics
NPI:1316587751
Name:UEBELACKER, SAMUEL MERRITT (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:MERRITT
Last Name:UEBELACKER
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 1:2855 E MAGIC VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6245
Mailing Address - Country:US
Mailing Address - Phone:208-639-4900
Mailing Address - Fax:
Practice Address - Street 1:2855 E MAGIC VIEW DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6245
Practice Address - Country:US
Practice Address - Phone:208-639-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-14
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant