Provider Demographics
NPI:1356854541
Name:DOGBEY, SAMUEL (PA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DOGBEY
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:PO BOX 9943
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-0943
Mailing Address - Country:US
Mailing Address - Phone:703-492-6822
Mailing Address - Fax:
Practice Address - Street 1:1990 OLD BRIDGE RD STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2383
Practice Address - Country:US
Practice Address - Phone:703-492-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA011005680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110005680Medicaid