MEDICARE: AMBER L PAYNE PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	AMD252	HI
2	363A00000X	Physician Assistant	PA07437	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A259554	OTHER	HI	HMSA, 65CP, HMSA QUEST
2	445343	OTHER	HI	UHA

General Provider Information

NPI Number	:	1104830686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER L PAYNE PAC

Provider Business Mailing Address
First Line	:	5701 BRYANT IRVIN RD STE 201
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4026
Country	:	US
Telephone Number	:	817-263-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 BRYANT IRVIN RD STE 201
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4026
Country	:	US
Telephone Number	:	817-263-2500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	02/28/2022

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Directions to “ AMBER L PAYNE PAC” Practice Location

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