Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207L00000X | Anesthesiologist | BP10077045 | TX |
NPI | 1003484072 |
---|---|
Provider Name | Heather Tisdale |
First Address | Galveston, TX 77555-5302 |
Second Address | Galveston, TX 77555-5302 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2021 |
Last Update Date | 15/06/2021 |