Provider Demographics
NPI:1740557552
Name:WILLBORN, MYRIAH (DO)
Entity Type:Individual
Prefix:
First Name:MYRIAH
Middle Name:
Last Name:WILLBORN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2406 HUNTER RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5255
Mailing Address - Country:US
Mailing Address - Phone:512-396-7686
Mailing Address - Fax:
Practice Address - Street 1:2406 HUNTER RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5255
Practice Address - Country:US
Practice Address - Phone:512-396-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX384201502Medicaid
TXP02601790OtherMCRR