Healthcare Provider Details

I. General information

NPI: 1750766986
Provider Name (Legal Business Name): ADAM TROY SAMS II CST/CSFA, LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5513 VENTURA ST
FORT WORTH TX
76244-6289
US

IV. Provider business mailing address

5513 VENTURA ST
FORT WORTH TX
76244-6289
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00751
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: