Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | K7809 | TX |
N | 207PE0004X | Emergency Medical Services | K7809 | TX |
NPI | 1205884202 |
---|---|
Provider Name | Jared Blaine Mabery |
First Address | Temple, TX 76502-7317 |
Second Address | Round Rock, TX 78681-4004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2006 |
Last Update Date | 21/11/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
122080805 | (05) | TX |
122080807 | (05) | TX |
G97507 | (02) | TX |
P00967092 | MEDICARE RAILROAD (01) | TX |