Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | G6262 | TX |
NPI | 1336473180 |
---|---|
Provider Name | Romeo Bachand |
First Address | Granbury, TX 76048 |
Second Address | Granbury, TX 76048-3823 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2009 |
Last Update Date | 28/09/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G6262 | TX LICENSE (01) | TX |