Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | M9126 | TX |
NPI | 1285838870 |
---|---|
Provider Name | Liliana Coromoto Andrade |
First Address | League City, TX 77573-6820 |
Second Address | League City, TX 77573-6820 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2007 |
Last Update Date | 06/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8CA588 | BLUE CROSS BLUE SHIELD (01) | TX |