Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | MD045994 | DC |
N | 208000000X | Pediatrician | T0196 | TX |
Y | 2080P0204X | Pediatric Emergency Doctor | T0196 | TX |
NPI | 1194136820 |
---|---|
Provider Name | Mrs. Angelica Wong Despain |
First Address | San Antonio, TX 78207-3255 |
Second Address | San Antonio, TX 78207-3108 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2014 |
Last Update Date | 21/06/2021 |