Provider Demographics
NPI:1508974213
Name:SAMPSON, PHILIP MERRILL (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:MERRILL
Last Name:SAMPSON
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 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-9093
Practice Address - Street 1:1140 MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1257
Practice Address - Country:US
Practice Address - Phone:209-394-7913
Practice Address - Fax:209-394-9093
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14693363A00000X
CAPA14693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14693Medicaid
CA0PA146931Medicare PIN
P40107Medicare UPIN