Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | L9961 | TX |
NPI | 1184731788 |
---|---|
Provider Name | Alexandra Wilson |
First Address | Austin, TX 78723-3079 |
Second Address | Austin, TX 78723-3079 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2006 |
Last Update Date | 29/12/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
168483902 | (05) | TX |