Provider Demographics
NPI:1639257025
Name:HALVERSON, SAMUEL HOLBROOK (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HOLBROOK
Last Name:HALVERSON
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 1:204 W HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29404-4704
Mailing Address - Country:US
Mailing Address - Phone:951-313-7307
Mailing Address - Fax:
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON AFB
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:951-313-7307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical