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General NPI Number Information
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NPI Number | 1740903434
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Entity Type | Organization
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Legal Business Name | INDIEMD TX MANAGEMENT LLC
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Dates
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Enumeration Date | 09/19/2022
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Last Update Date | 08/28/2024
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Provider Practice Location Address
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Address Line | 309 WATER ST STE 108
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City | BOERNE
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State | TX
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Zip | 78006-2866
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Country | US
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Telephone | 877-988-7420
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Fax |
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Provider Business Mailing Address
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Address Line | 309 WATER ST STE 108
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City | BOERNE
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State | TX
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Zip | 78006-2866
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Country | US
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Telephone | 877-988-7420
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JASON RYAN FRAZIER
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Credential |
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Telephone | 877-988-7420
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202D00000X
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Taxonomy Name | Integrative Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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