Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | AP135830 | TX |
NPI | 1023521762 |
---|---|
Provider Name | Henry Bullock |
First Address | San Antonio, TX 78215-1086 |
Second Address | San Antonio, TX 78229-3367 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2017 |
Last Update Date | 15/11/2017 |