Facts
- Status
- A
- Credential
- NP
- Type
- Individual
- Enumeration date
- 2020-01-27
- Last updated
- 2020-01-27
Licenses
- License TX
- AP144436
Location
- Practice location
- 230 SHEPHERD HL
- City
- CANYON LAKE TX
- Postal code
- 781335606
- Phone
- 210-332-2160
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.