Provider Demographics
NPI:1962916502
Name:MCCOMBER, SAMUEL DALLAS (RN)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DALLAS
Last Name:MCCOMBER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:DALLAS
Other - Last Name:MCCOMBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:670 9TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6249
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:785 18TH ST
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-5683
Practice Address - Country:US
Practice Address - Phone:707-822-2481
Practice Address - Fax:707-822-3656
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95146216163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse