Provider Demographics
NPI:1962035576
Name:WULF, SAMONE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMONE
Middle Name:MARIE
Last Name:WULF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMONE
Other - Middle Name:MARIE
Other - Last Name:PABST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3901 PINE LAKE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5497
Mailing Address - Country:US
Mailing Address - Phone:402-420-3417
Mailing Address - Fax:402-328-0961
Practice Address - Street 1:3901 PINE LAKE RD STE 120
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5497
Practice Address - Country:US
Practice Address - Phone:402-420-1212
Practice Address - Fax:402-328-0961
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant