Basic Information
| Provider Information | |||||||||
| NPI: | 1093231631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TEMPLE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 11538 | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765471538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459177 | ||||||||
| FaxNumber: | 2542459178 | ||||||||
| Practice Location | |||||||||
| Address1: | 3800 S W S YOUNG DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | KILLEEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765423340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542459175 | ||||||||
| FaxNumber: | 2542137771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0000X | 758325 | TX | N | Nursing Service Providers | Registered Nurse | Pain Management | 363LF0000X | AP135444 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 377453101 | 05 | TX | MEDICAID |