Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | AP141365 | TX |
NPI | 1033670245 |
---|---|
Provider Name | Travis Casillas |
First Address | Roanoke, TX 76262-3473 |
Second Address | Dallas, TX 75235-7701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/03/2019 |
Last Update Date | 13/04/2019 |