Provider Demographics
NPI:1356013262
Name:DEVORE, SAMUEL PHILIP (PA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PHILIP
Last Name:DEVORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6759 N WATERLILLY WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-4043
Mailing Address - Country:US
Mailing Address - Phone:541-910-0627
Mailing Address - Fax:
Practice Address - Street 1:100 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3692
Practice Address - Country:US
Practice Address - Phone:509-933-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant