Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT1587 | TX |
Y | 213ES0000X | Sports Medicine | AT1587 | TX |
NPI | 1093214611 |
---|---|
Provider Name | Tim Moore |
First Address | San Antonio, TX 78247-2057 |
Second Address | San Antonio, TX 78259-2203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2018 |
Last Update Date | 09/02/2018 |