Provider Demographics
NPI:1700419181
Name:DESOUZA, SAMUEL KOBINA JR (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KOBINA
Last Name:DESOUZA
Suffix:JR
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 1:1500 S DOBSON RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4724
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:
Practice Address - Street 1:1500 S DOBSON RD STE 202
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4724
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program