Provider Demographics
NPI:1609382050
Name:RICHARDS, SAMUEL STEPHEN (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:STEPHEN
Last Name:RICHARDS
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 1:5848 S FASHION BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6175
Mailing Address - Country:US
Mailing Address - Phone:801-314-5026
Mailing Address - Fax:801-314-4015
Practice Address - Street 1:5848 S FASHION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6175
Practice Address - Country:US
Practice Address - Phone:801-314-5026
Practice Address - Fax:801-314-4015
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10622246-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical