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General NPI Number Information
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NPI Number | 1831799238
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Entity Type | Individual
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Provider Name | JERRY GEORGE GREESON MED, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 10/27/2020
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Last Update Date | 10/27/2020
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Provider Practice Location Address
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Address Line | 2239 WALKER AVE BLDG 5570
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City | JBSA LACKLAND
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State | TX
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Zip | 78236-5632
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Country | US
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Telephone | 210-365-8316
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Fax |
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Provider Business Mailing Address
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Address Line | 24526 DREW GAP
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City | SAN ANTONIO
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State | TX
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Zip | 78255-2284
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Country | US
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Telephone | 210-365-8316
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PS0010X
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Taxonomy Name | Sports Medicine (Emergency Medicine) Physician
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License Number | AT0646
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License Number State | TX
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