Basic Information
| Provider Information | |||||||||
| NPI: | 1053400135 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACABE-MOORE | ||||||||
| FirstName: | WYNTRIA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 SUNSET TERRACE DR | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775737793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813392916 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1403 HIGHWAY 6 | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774784930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8322600640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 05/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M4259 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | M4259 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 179352303 | 05 | TX | MEDICAID | P00459908 | 01 | TX | RAILROAD MEDICARE | OTHER | 8V1563 | 01 | TX | BCBSTX | OTHER |