Provider Demographics
NPI:1104830686
Name:PAYNE, AMBER L (PAC)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:L
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BRYANT IRVIN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4026
Mailing Address - Country:US
Mailing Address - Phone:817-263-2500
Mailing Address - Fax:
Practice Address - Street 1:5701 BRYANT IRVIN RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4026
Practice Address - Country:US
Practice Address - Phone:817-263-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD252363A00000X
TXPA07437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIA259554OtherHMSA, 65CP, HMSA QUEST
HI445343OtherUHA
HIH100793Medicare PIN
HI445343OtherUHA
TX289161YKPWMedicare PIN