Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | M0769 | TX |
NPI | 1174579593 |
---|---|
Provider Name | John Gordon Johnson |
First Address | Georgetown, TX 78628-4678 |
Second Address | Round Rock, TX 78681-4004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PENDING | (02) | TX |