Provider Demographics
NPI:1518539196
Name:FANUA, SAMUELA JR (PA)
Entity Type:Individual
Prefix:
First Name:SAMUELA
Middle Name:
Last Name:FANUA
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2968 YORKTOWN CT
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 E HARDING WAY STE D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6118
Practice Address - Country:US
Practice Address - Phone:209-944-5750
Practice Address - Fax:209-464-2684
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant