Provider Demographics
NPI:1154619922
Name:PALOS, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:PALOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832A MOUNTAIN LAUREL CIR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87116-1249
Mailing Address - Country:US
Mailing Address - Phone:575-635-3833
Mailing Address - Fax:
Practice Address - Street 1:255 HIGHWAY 187
Practice Address - Street 2:
Practice Address - City:HATCH
Practice Address - State:NM
Practice Address - Zip Code:87937-7001
Practice Address - Country:US
Practice Address - Phone:575-267-3088
Practice Address - Fax:575-267-4565
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-4917235Z00000X
390200000X
NMPA2023-0300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program