Provider Demographics
NPI:1770972184
Name:SAMAFUHBI, DERICK N (PA-C)
Entity type:Individual
Prefix:MR
First Name:DERICK
Middle Name:N
Last Name:SAMAFUHBI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1215
Mailing Address - Street 2:ATTN CLINIC BILLING OFFICE
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1215
Mailing Address - Country:US
Mailing Address - Phone:620-629-6638
Mailing Address - Fax:620-629-6684
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-629-6477
Practice Address - Fax:620-629-6651
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110005063363A00000X
NY024081-01363A00000X
KS1501801363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200631770AMedicaid
KS201134920AMedicaid
KS201134920AMedicaid