Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | J2873 | TX |
NPI | 1376552612 |
---|---|
Provider Name | Roberta Lee Fennig |
First Address | El Paso, TX 79912-4442 |
Second Address | El Paso, TX 79912-4442 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E0694 | (05) | NM |