Provider Demographics
NPI:1952627986
Name:SAMPOGNA, MARINA J (PA)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:J
Last Name:SAMPOGNA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:JOY
Other - Last Name:WAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-5600
Mailing Address - Fax:208-302-5655
Practice Address - Street 1:10255 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1430
Practice Address - Country:US
Practice Address - Phone:208-302-5600
Practice Address - Fax:208-302-5655
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363AM0700X
VA0110003294363AM0700X
IDPA-1049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical