Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | PA05379 | TX |
NPI | 1013175876 |
---|---|
Provider Name | Marvin A Andrade |
First Address | Pharr, TX 78577-3117 |
Second Address | Pharr, TX 78577-3117 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/05/2008 |
Last Update Date | 28/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PA05379 | STATE LICENSE (01) | TX |