NPIMap

Individual provider Active NPI

Samuel Jolley, PA-C

  • Physician Assistant
  • Woodbury, MN
National Provider Identifier
1336798222
Registry record updated Aug 20, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
15239 Issued in MN
Practice address
6025 Lake Rd Ste 200
Woodbury, MN 55125-1710
Phone
(651) 999-6800
NPI assigned
Sep 4, 2019
Last updated
Aug 20, 2025By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 20, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 15239 MN Primary

Addresses

Primary practice location

6025 Lake Rd Ste 200
Woodbury, MN 55125-1710

Mailing address

3001 Metro Dr Ste 460
Bloomington, MN 55425-1548
Phone (651) 999-6800

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SD, MS, MN3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20191028003328 SD Practitioner - Physician Assistant 4385976182 Reassigns benefits to 1 organization
I20210608000375 MS Practitioner - Physician Assistant 4385976182 Reassigns benefits to 1 organization
I20250807000989 MN Practitioner - Physician Assistant 4385976182 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Minnesota Urology, PAGroup PAC ID 0840183984, 83 clinicians

Practice addresses (Care Compare)

1185 Town Centre Dr
Eagan, MN 55123-1189
Phone (651) 999-6800

500 Osborne Rd NE
Suite 120
Fridley, MN 55432-2767
Phone (651) 999-6800

6025 Lake Rd
Suite 200
Woodbury, MN 55125-1710
Phone (651) 999-6800

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
15239MNMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
State of Mississippi - University of Mississippi Medical Center CurrentSince Jul 1, 2021 Accepting new patients
State of Mississippi - University of Mississippi Medical Center CurrentSince Jul 1, 2021 Accepting new patients
Metropolitan Urologic Specialists PA PastSince Aug 25, 2025 Accepting new patients

Locations

2500 N State St
Jackson, MS 39216
Phone (601) 815-4775

2500 N State St
#4300
Jackson, MS 39216

Interoperability endpoints

  • Direct secure messaging: samuel.jolley.1@20581.direct.athenahealth.com

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 17

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1567555200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1755648000000",
    "number": "1336798222",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3001 METRO DR STE 460",
            "city": "BLOOMINGTON",
            "state": "MN",
            "postal_code": "554251548",
            "telephone_number": "651-999-6800",
            "fax_number": "651-999-6970"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6025 LAKE RD STE 200",
            "city": "WOODBURY",
            "state": "MN",
            "postal_code": "551251710",
            "telephone_number": "651-999-6800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JOLLEY",
        "first_name": "SAMUEL",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-09-04",
        "last_updated": "2025-08-20",
        "certification_date": "2025-08-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MN",
            "license": "15239",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Woodbury, MN

Sources for this page

Verify at the official NPI Registry.