Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | M8674 | TX |
Y | 207QS0010X | Family Doctor - Sports Medicine | M8674 | TX |
NPI | 1154582716 |
---|---|
Provider Name | Kory Lee Gill |
First Address | Bryan, TX 77802-2622 |
Second Address | Bryan, TX 77802-3499 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/06/2008 |
Last Update Date | 27/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
201122301 | (05) | TX |
8BZ695 | BCBS (01) | TX |