Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | R9466 | TX |
Y | 207Q00000X | Family Doctor | R9466 | TX |
NPI | 1275073215 |
---|---|
Provider Name | Elizabeth Svyatoslavna Balyakina |
First Address | San Antonio, TX 78207-0903 |
Second Address | San Antonio, TX 78223-1703 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2017 |
Last Update Date | 04/08/2021 |