Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | L6736 | TX |
NPI | 1033218730 |
---|---|
Provider Name | Marlo Brawner |
First Address | Livinston, TX 77351 |
Second Address | Livingston, TX 77351-6783 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/09/2006 |
Last Update Date | 21/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
159580303 | (05) | TX |
169920902 | (05) | TX |
21239 | CHOICE ONE CHIPS (01) | TX |
8P9491 | BCBS NUMBER (01) | TX |
H39037 | (02) | TX |