Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 672526 | TX |
NPI | 1023287794 |
---|---|
Provider Name | Roberto B. D'lorm |
First Address | Lago Vista, TX 78645-6456 |
Second Address | Lago Vista, TX 78645-6456 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2008 |
Last Update Date | 31/01/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
672526 | GNP LICENSE (01) | TX |