Provider Demographics
NPI:1922073634
Name:DOSTAL, SAMUEL J (PA C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:J
Last Name:DOSTAL
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6900 A ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-4120
Mailing Address - Country:US
Mailing Address - Phone:402-436-2000
Mailing Address - Fax:402-434-2691
Practice Address - Street 1:6900 A ST
Practice Address - Street 2:STE 100
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4120
Practice Address - Country:US
Practice Address - Phone:402-436-2000
Practice Address - Fax:402-436-2090
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1217363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE247112OtherMIDLANDS CHOICE
NE91177983268510A019OtherTRI CARE
NE91177983268510A019OtherTRI CARE
NE279441Medicare PIN