Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 507591 | TX |
NPI | 1023074465 |
---|---|
Provider Name | Gwendolen Wood |
First Address | Lubbock, TX 79407-3544 |
Second Address | Lubbock, TX 79424-3367 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S76958 | (02) |