Provider Demographics
NPI:1760927040
Name:MOORE, SAMANTHA GERMAINE (NP)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:GERMAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:GERMAINE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1300 W TERRELL AVE STE K230
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3104
Mailing Address - Country:US
Mailing Address - Phone:817-250-4906
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3104
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132837363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP132837OtherSTATE LICENSE
TX556813YNGSMedicare PIN
TX556813YL7BMedicare PIN
TX556813YL7AMedicare PIN