Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | G4018 | TX |
NPI | 1053363531 |
---|---|
Provider Name | Ladonna L Immken |
First Address | Austin, TX 78723-3078 |
Second Address | Austin, TX 78731-3146 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2006 |
Last Update Date | 10/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
136490301 | (05) | TX |
136490305 | (05) | TX |
B23691 | (02) | TX |