Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2086S0120X | Pediatric Surgery | E-4664 | AR |
N | 208G00000X | Cardiothoracic Vascular Surgeon | 2010-01391 | NC |
N | 208G00000X | Cardiothoracic Vascular Surgeon | E-4664 | AR |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | R1549 | TX |
NPI | 1356432553 |
---|---|
Provider Name | Robert Jaquiss |
First Address | Dallas, TX 75235-7701 |
Second Address | Dallas, TX 75235-7701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 12/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
158664001 | (05) | AR |
G10412 | (02) |