Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | S4490 | TX |
Y | 213ES0000X | Sports Medicine | S4490 | TX |
NPI | 1194103036 |
---|---|
Provider Name | Alexandria Joann Haselhorst |
First Address | Austin, TX 78731-6406 |
Second Address | Chicago, IL 60611-3167 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2015 |
Last Update Date | 05/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S4490 | TEXAS MEDICAL LICENSE (01) | TX |