Basic Information
| Provider Information | |||||||||
| NPI: | 1982667283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547248800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 UNIVERSITY DR E | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778402661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9796913300 | ||||||||
| FaxNumber: | 9796913099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00825 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8N9138 | 01 | TX | BLUE SHIELD | OTHER |