Provider Demographics
NPI:1558729251
Name:PALOMARES, SAMANTHA JO ADCOCK (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JO ADCOCK
Last Name:PALOMARES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:ADCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1100 ALLIED DR STE 2-862
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5348
Mailing Address - Country:US
Mailing Address - Phone:740-405-5051
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA10509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3314619-01Medicaid