Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1800X | Optician | 192472 | TX |
NPI | 1124783881 |
---|---|
Provider Name | Fidel Alexander Pantoja |
First Address | San Antonio, TX 78225-2244 |
Second Address | San Antonio, TX 78225-2244 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2021 |
Last Update Date | 23/11/2021 |