Provider Demographics
NPI:1427012988
Name:SKINNER, SAMUEL SHAWN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:SHAWN
Last Name:SKINNER
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 1:1535 GULL RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-385-9900
Mailing Address - Fax:269-385-2140
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-385-9900
Practice Address - Fax:269-385-2140
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003954363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM37340006Medicare ID - Type Unspecified
MIQ18368Medicare UPIN