THE INFURMATIDH IN THIS EDI WAS REPCIRTED E'i" THE LICENSEE AND
HAS HUT BEEN ET THE TEIAE MEDICAL EDAHD

Sender: MALE

*Ethnicity: HISPANIC

Race: WHITE - cf Hispanic crigin

We are in the prccess cf transiticning the current ethnic engin yalues tc federal
standards race and Hispanic crigin. The transiticn pencd will time indiyiduals
tc submit updated race and Hispanic crigin data tc the TMS.

Place at Birth: NEW TCIRH.

Current Primary Practice Address:

3925 SAHLER RCAD

MANMEL TI TTSTEI

?tears at Active Practice in the US. er Canada:
The physician that her'she has actiyely practiced medicine in
the United States cr Canada 29 yearts}.

?tears at Active Practice in Texas:
The physician that, at the abcye years her'she has actiyely practiced in
the State cf Texas far 29 yea nIs}.

Specialty Beard Certification

The physician that hershe the specialty certi?catic ns issued by a
beard that is a member at the American Elcard cf Medical Specialties er the Bureau at
Cstecpathic Specialists:

Specialty Certi?catien: AMERICAN SCARD CF 
NELIRCILCISWCHI LDSADCILESCENT R?i"
Date: 

Specialty Certi?catien: AMERICAN SCARD CF 

Date: 

Primary Specialty
The physician hisfher pn'mary practice is in the area at 

Secendary Specialty
The physician re his;r er seccndary practice is in the area cf CHILD AND
ADCILESCENT