Provider Demographics
NPI:1538126545
Name:SAMP, CHARLES M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:SAMP
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 1:6242 E ARBOR AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1309
Mailing Address - Country:US
Mailing Address - Phone:480-610-8183
Mailing Address - Fax:480-089-5311
Practice Address - Street 1:6242 E ARBOR AVE
Practice Address - Street 2:STE 111
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1309
Practice Address - Country:US
Practice Address - Phone:480-610-8183
Practice Address - Fax:480-895-3110
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1554363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578841Medicaid
AZR32486Medicare UPIN
AZ578841Medicaid