Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | F3228 | TX |
NPI | 1013967413 |
---|---|
Provider Name | Van S Mask |
First Address | Belton, TX 76513-0914 |
Second Address | Temple, TX 76502-1814 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C18913 | (02) | TX |