Provider Demographics
NPI:1619683489
Name:PRINCE, SAMUEL PHILLIP (PTA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:PHILLIP
Last Name:PRINCE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 WESTLAWN ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-2012
Mailing Address - Country:US
Mailing Address - Phone:505-604-4151
Mailing Address - Fax:
Practice Address - Street 1:3304 WESTLAWN ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-2012
Practice Address - Country:US
Practice Address - Phone:505-604-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20126882081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine