Provider Demographics
NPI:1023902533
Name:PAYNE, SAMUEL DUSTIN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DUSTIN
Last Name:PAYNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W MIKAN DR APT 12202
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-8056
Mailing Address - Country:US
Mailing Address - Phone:208-760-5688
Mailing Address - Fax:
Practice Address - Street 1:1820 E 17TH ST STE 330
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6400
Practice Address - Country:US
Practice Address - Phone:208-497-0685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-07
Last Update Date:2025-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management