MEDICARE: SAMANTHA MARIE WATTS PA-C

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	208M00000X	Hospitalist Physician	193400000X	TX
2	363A00000X	Physician Assistant	PA12869	TX

General Provider Information

NPI Number	:	1043877384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MARIE WATTS PA-C

Provider Business Mailing Address
First Line	:	3408 GRANTS LNDG
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3853
Country	:	US
Telephone Number	:	435-659-9821
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 8TH AVE STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4158
Country	:	US
Telephone Number	:	817-912-8240
Fax Number	:

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

Provider Enumeration Date	:	05/22/2019
Last Update Date	:	05/30/2023

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