Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 0101255839 | VA |
Y | 111NI0900X | Internist | 0101255839 | VA |
N | 208D00000X | General Practice Physician | 0101255839 | VA |
NPI | 1003177593 |
---|---|
Provider Name | Danielle Kusserow Bersabe |
First Address | Lackland Afb, TX 78233 |
Second Address | Lackland A F B, TX 78236-9907 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2012 |
Last Update Date | 07/10/2015 |