Provider Demographics
NPI:1154352854
Name:VERBECK, SAMUEL S JR (RPA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:S
Last Name:VERBECK
Suffix:JR
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3 BRIDGE STREET
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-1323
Mailing Address - Country:US
Mailing Address - Phone:315-493-7334
Mailing Address - Fax:315-493-1811
Practice Address - Street 1:3 BRIDGE STREET
Practice Address - Street 2:SUITE 3
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-1323
Practice Address - Country:US
Practice Address - Phone:315-493-7334
Practice Address - Fax:315-493-1811
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY004138363A00000X
NY004138-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02751059Medicaid
NYJ400001477Medicare PIN
S54669Medicare ID - Type Unspecified
NY02751059Medicaid