Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | AP141025 | TX |
NPI | 1013489061 |
---|---|
Provider Name | Jared Blake Griffin |
First Address | Dallas, TX 75284-8491 |
Second Address | Waco, TX 76712-8897 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/12/2018 |
Last Update Date | 04/01/2022 |