Provider Demographics
NPI:1376590059
Name:IRVINE, SAMUEL OLIVER STARKE JR (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:OLIVER STARKE
Last Name:IRVINE
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 1:454 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3563
Mailing Address - Country:US
Mailing Address - Phone:334-613-9000
Mailing Address - Fax:334-532-0056
Practice Address - Street 1:454 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-613-9000
Practice Address - Fax:334-532-0056
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-189363AS0400X
ALPA.189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009934027Medicaid
AL009989995Medicaid
AL009989985Medicaid
AL051001143OtherBLUE CROSS - 860 MONT RD
AL051001307OtherBLUE CROSS - 48 MED PARK
AL051001308OtherBLUE CROSS - 2660 10TH AV
P35188Medicare UPIN
AL009989985Medicaid