Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 812655 | TX |
NPI | 1104382597 |
---|---|
Provider Name | Mrs. Amy Jo Shuptrine |
First Address | Frankston, TX 75763-6734 |
Second Address | Athens, TX 75751-5610 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/02/2019 |
Last Update Date | 11/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
15390359 | TEXAS DRIVERS LICENSE (01) | TX |