Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 641349 | TX |
NPI | 1003978313 |
---|---|
Provider Name | Tandra Medellin |
First Address | Galveston, TX 77555-1022 |
Second Address | Galveston, TX 77555-1022 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 08/08/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q31794 | (02) | TX |