Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0004X | Health Psychologist | 593 | WY |
NPI | 1750708863 |
---|---|
Provider Name | Dr. John Anthony Blue Star |
First Address | Jbsa Lackland, TX 78236-5638 |
Second Address | Lackland Afb, TX 78236-5638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2014 |
Last Update Date | 13/09/2020 |