Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2006034474 | MO |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | Q9277 | TX |
NPI | 1285660076 |
---|---|
Provider Name | Maria Pharah Pagusara Ambalong |
First Address | Dallas, TX 75243-3224 |
Second Address | Dallas, TX 75243-3224 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2006 |
Last Update Date | 07/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
207455304 | (05) | MO |
365729801 | (05) | TX |