Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RP1001X | Pulmonary Disease | L8581 | TX |
NPI | 1043237076 |
---|---|
Provider Name | Pathom Thavaradhara |
First Address | Pampa, TX 79065-2814 |
Second Address | Pampa, TX 79065-2814 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2006 |
Last Update Date | 25/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
167273501 | (05) | TX |
8M7360 | BLUE CROSS/BLUE SHIELD (01) | TX |
D49465 | (02) | TX |
P00209318 | RAILROAD MEDICARE, PALMETTO GBA (01) |