Provider Demographics
NPI:1164144820
Name:KING, SAMANTHA RAE (LAT, ATC)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:RAE
Last Name:KING
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 HULEN PL APT 418
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7380
Mailing Address - Country:US
Mailing Address - Phone:303-288-5067
Mailing Address - Fax:
Practice Address - Street 1:3500 BELLAIRE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:862-380-0003
Practice Address - Fax:817-257-7323
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT9017207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine