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9/] 2/20l5 Welcome to the TMB Website

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9/I2/2015 Welcome to the TMB Website

Status History

Status history contains entries for any updates to the individual's ...
9/I2/2015 Welcome to the TMB Website

Date:  2002

Specialty Certification:  AMERICAN BOARD OF PEDIATRICS
Date:  1999

Prim...
9/ I 2/2015 Welcome to the TMB Website

Accessibility:  The physician reports that the patient service area is accessible ...
9/ I 2/20|5 Welcome to the TMB Website

The physician has reported the following: 

Description:  NONE

To obtain
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9/I2/20|5 Welcome to the TMB Website

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9/12/20 I 5 Welcome In the TMB Website

Educafion

Graduation Year:  1987

Medical School:  UNIV CENTRAL DEL CARIBE,  ESCUE...
9/I2/2015 Welcome to the TMB Website
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9/I 2/2()I5 Welcome to the TMB Website

Status History

Status history contains entries for any updates to the individual'...
9/I2/20l5 Welcome to the TMB Website

Secondary Specialty
The physician did not report a secondary practice area. 

Name, ...
9/I 2/20] 5 Welcome to the TMB Website

NONE

Malpractice Information

Section 154.006(b)(16) of the Act requires that:  a...
9/I2/2015 Welcome to the TMB Website

Advanced Practice Nurse Delegation = °l{r_¢e , 
verifications, 

click name

Descrip...
9/I2/2015 Welcome to the TMB Website

TEXAS
MEDICAL

BOARD

 

PUBLIC VERIFICATION I PHYSICIAN PROFILE

PHYSICIAN ASSISTAN...
9/ I 2/20 I 5 Welcome to the TMB Website

Description:  LICENSE ISSUED

THE INFORMATION IN THIS BOX WAS REPORTED BY THE LI...
9/I2/20|5 Welcome to the TMB Website

TEXAS
MEDICAL

BOARD

 

PUBLIC VERIFICATION I PHYSICIAN PROFILE

PHYSICIAN

NAME:  ...
9/I2/20I5 Welcome to the TMB Website

Status History

Status history contains entries for any updates to the individual’s ...
9/I2/ZOIS Welcome to the TMB Website

Secondary Specialty
The physician did not report a secondary practice area. 

Name, ...
9/I 2/ZOIS Welcome to the TMB Wchsitc

NONE

Malpractice Information

Section 154.006(b)(16) of the Act requires that:  a ...
9/I2/2015 Welcome to the TMB Website

Dangerous Drugs:  YES
Controlled Substances:  YES

Physician Assistant Name:  CARMON...
9/|  2/20 I 5 Welcome to the TMB Website

 
 

Hours Supervised:  40
Dangerous Drugs:  YES
Controlled Substances:  YES

  ...
9/I2/20I5 NPI Registry Provider Details

. '.' NPPES

National Plan 6’.  Pro vfder Enumeration System Home He", 

 

Back ...
9/I2/20l5 NPI Registry Provider Details

YES 208000000X - PEDIATRICS OH 35.089897

Other Provider Identifier: 

Issuer N u...
9/I2/2015 NPI Registry Provider Details

25.75 / C/ PPES

National Plan 6’.  Provider Enumeration System Home He“, 

 

Ba...
9/I2/20I5 NPI Registry Provider Details

YES 183500000X - PHARMACIST TX 53952

Other Provider Identifier: 

Issuer Number ...
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9/I2/2015 Welcome to the TMB Website

Status History

Status history contains entries for any updates to the individual's ...
9/I2/20l5 Welcome to the TMB Website

The physician reports his/ her primary practice is in the area of PSYCHIATRY. 

Seco...
9/I2/20I5 Welcome to the TMB Website

Awards,  Honors,  Publications and Academic Appointments

Optional Information
The p...
9/12/20I5

Welcome to the TMB Website

Description:  NONE

Advanced Practice Nurse Delegation

Description:  NONE

Summary...
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Medical personnel children jail

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Here is a partial list of confirmed Physicians & Physicians Assistants that make the incarceration of toddlers possible in Dilley, Texas.

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Medical personnel children jail

  1. 1. 9/] 2/20l5 Welcome to the TMB Website I . - ’ . ... ., ‘. ,iTT'7'. T T V _ | =*‘. __; _._= '~_‘, . ‘ . ,y , . I ‘, I I - v I V’ I. ‘ I i : .l/ .E. :.3l. lC. -=. .__. . I -' . F V . .. 4. r m ( ‘ " ' _ ' P. .. f‘i A -(‘"5 I _ ‘, ‘k I ‘ . . l -"-4-"‘-*--/ " " N . - L , . — . ___‘ I. 14.. ..“ _. t___ I PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN DATE: 09/12/2015 NAME: ROCHELLE ROXANNE FLYNN MD THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1970 License Number: N3643 Full Medical License Issuance Date: 08/21/2009 Expiration Date of Physician’s Registration Permit: 05/31/2017 Registration Status: ACTIVE Disciplinary Status: NONE Licensure Status: NONE Registration Date: 08/26/2009 Disciplinary Date: NONE Licensure Date: NONE Medical School of Graduation: At the time of licensure, TMB verified the physician's graduation from medical school as follows: GEORGE WASHINGTON UNIV SCH OF MED 8. HLTH SCI, WASHINGTON Medical School Graduation Year: 1996 TMB Filings, Actions and License Restrictions The Texas Medical Board has the following board actions against this physician. (This may include any formal complaints filed by TMB, as well as petitions and/ or responses related to licensure contested matters, at the State Office of Administrative Hearings. ) NONE Investigations by TMB of Medical Malpractice Section 164.201 of the Act requires that: the board review information relating to a physician against whom three or more malpractice claims have been reported within a five year period. Based on these reviews, the following investigations were conducted with the listed resolutions. NONE http: //ri: g.Imh. st.1Ic. t . us/ OnLincVcrif/ Ph_ s_ReportVerif_new asp I/5
  2. 2. 9/I2/2015 Welcome to the TMB Website Status History Status history contains entries for any updates to the individual's registration, licensure or disciplinary status types (beginning with 1/1/78, when the board‘s records were first automated). Entries are in reverse chronological order; new entries of each type supersede the previous entry of that same type. These records do not display status type. Should you have any questions, please contact our Customer Information Center at 512-305-7030 or verifcic tm . tat . tx. us Status Code: AC Effective Date: 08/26/2009 Description: ACTIVE Status Code: Ll Effective Date: 08/21/2009 Description: LICENSE ISSUED THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: FEMALE *Ethnicity: DID NOT ANSWER Race: WHITE * We are in the process of transitioning from the current ethnic origin values to federal standards for race and Hispanic origin. The transition period will allow time for individuals to submit updated race and Hispanic origin data to the TMB. Place of Birth: NEW JERSEY Current Primary Practice Address: SOUTH TEXAS FAMILY RESID CTR 1925 W. HIGHWAY 85 DILLEY , TX 78017 Years of Active Practice in the U. S. or Canada: The physician reports that he/ she has actively practiced medicine in the United States or Canada for 17 year(s). Years of Active Practice in Texas: The physician reports that, of the above years he/ she has actively practiced in the State of Texas for 5 year(s). Specialty Board Certification The physician reports that he/ she holds the following specialty certifications issued by a board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists: Specialty Certification: AMERICAN BOARD OF PEDIATRICS/ PEDIATRIC EMERGENCY MEDICINE hup: //reg . tmh. stalc. t . us/ On LincVcrif/ l’hys_RcportVc-riLncw . asp
  3. 3. 9/I2/2015 Welcome to the TMB Website Date: 2002 Specialty Certification: AMERICAN BOARD OF PEDIATRICS Date: 1999 Primary Specialty The physician reports his/ her primary practice is in the area of PEDIATRICS. Secondary Specialty The physician reports his/ her secondary practice is in the area of PEDIATRIC EMERGENCY MEDICINE (PEDS). Name, Location and Graduation Date of All Medical Schools Attended Name: GEORGE WASHINGTON UNIV SCH OF MED & HLTH SCI, WASHINGTON Location: Graduation Date: 05/1996 Graduate Medical Education In The United States Or Canada Program Name: TOD CHILDREN S HOSPITAL Location: YOUNGSTOWN, OH Begin Date: 07/1996 Type: RESIDENCY End Date: 06/1999 Specialty: PEDIATRICS Program Name: TOD CHILDREN'S HOSPITAL Location: YOUNGSTOWN, OH Begin Date: 07/1999 Type: FELLOWSHIP End Date: 06/2002 Specialty: PEDIATRIC EMERGENCY MEDICINE Hospital Privileges The physician reports that he/ she has hospital privileges in the following in the State of Texas: NONE Utilization Review The physician did not report whether he/ she provides utilization review. NONE REPORTED Patient Services lillp: //rcg. tmh. statc. lx . us/ ()nl. ineVcrif/ Phys_RcportVeril'_ne'. asp 3/5
  4. 4. 9/ I 2/2015 Welcome to the TMB Website Accessibility: The physician reports that the patient service area is accessible to persons with disabilities as defined by federal law. Language Translation Services: The physician reports that the following language translation services are provided for patients: SPANISH, SOME SAM/ CENTAM DIALECTS Medicaid Participant: The physician reports that he/ she does participate in the Medicaid program. Awards, Honors, Publications and Academic Appointments Optional Information The physician may optionally report descriptions of up to five such honors and has reported the following: Description: CLINICAL ASSOCIATE PROFESSOR AT TEXAS A&M Malpractice Information Section 154.006(b)(16) of the Act requires that: a physician profile display a description of any medical malpractice claim against the physician, not including a description of any offers by the physician to settle the claim, for which the physician was found liable, a jury awarded monetary damages to the claimant, and the award has been determined to be final and not subject to further appeal. The physician has the following reportable claims. Description: NONE Criminal History Self-Reported Criminal Offenses: The physician is required to report a description of (1) "any conviction for an offense constituting a felony, a Class A or Class B misdemeanor, or a Class C misdemeanor involving moral turpitude" and (2) "any charges reported to the board to which the physician has pleaded no contest, for which the physician is the subject of deferred adjudication or pretrial diversion, or in which sufficient facts of guilt were found and the matter was continued by a court of competent jurisdiction. " The physician has reported the following: Description: NONE Criminal history information is also obtained by TMB from the Texas Department of Public Safety. Resulting action, if any, will be reported under the TMB Action and Non-Disciplinary Restrictions section above. Disciplinary Actions By Other State Medical Boards htlp: //reg. tmb. sta! c.l. us/ OnLineVcrif/ Ph) s_RcportV€rif_nev'. asp
  5. 5. 9/ I 2/20|5 Welcome to the TMB Website The physician has reported the following: Description: NONE To obtain _ _ _ _ primary Physician Assistant Supervision source verifications, click name Description: NONE To obtain primary Advanced Practice Nurse Delegation source verifications, click name Description: NONE Summary of all LicenseIPermit Types Issue Date: Type: 08/21/2009 LICENSED PHY I IAN Contact Us ] Privacy Policy 1 Accessibility Policy | Compact with Texans | Website Linking Policy Please contact Pre-Licensure, Registration and Consumer Services at (512) 305-7030 for assistance. http: //rcg . tmb. statc. t . us/ Onl . i ncVcriI‘/ I’h) s_RcportVeril'_new asp
  6. 6. 9/I2/20|5 Welcome to the TMB Website - _e 7 . ‘ 3 -'‘y ' q, I I I — ‘. :._ul‘. i.«""J-f-I ‘ I I '1 ’_ _ gr I EJCD. -5.»3iI. ::x *» ; «I PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN IN TRAINING PERMIT NAME: ROSA IVELISSE COLON MD DATE: 09/12/2015 THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1962 Permit Number: BP10045161 Permit Type: PHYSICIAN IN TRAINING PERMIT Permit Status: PERMIT TERMINATED Permit Status Date: 7/29/2012 Begin Date: 07/21/2012 Expiration Date: 07/29/2012 End Date: 07/29/2012 Terminated Date: 07/29/2012 Mailing Address TX DEPT OF STATE HEALTH SVS HSR 11 601 SESAME ST HARLINGEN , TX 78550 Board Action (includes all actions regardless of licenselpermit type) NONE THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: Current Primary Practice Address: NOT GIVEN http: //reg. tmh. state. lx. us/ On LineVcrif/ Ph_'s_ReportVeri I_neW. asp I/2
  7. 7. 9/12/20 I 5 Welcome In the TMB Website Educafion Graduation Year: 1987 Medical School: UNIV CENTRAL DEL CARIBE, ESCUELA DE MED, CAYEY Program Type: FELLOWSHIP Training Institution: DEPT OF STATE HEALTH SERVICES, OPERATION LONESTAR Program Specialty: PREVENTIVE MED/ PUBLIC HEALTH Summary of all LicenselPermit Types Issue Date: Type: 07/21/2012 PHYSICIAN IN TRAINING PERMIT Contact Us | Privacy Policy | Accessibility Policy | Compact with Texans | Website Linking Policy Please contact Pre—Licensure, Registration and Consumer Services at (512) 305-7030 for assistance, http: //reg. tmh. state. tx. us/ OnI. ineVeri I/ Pliy s_ReportVen' f_new. asp 2/2
  8. 8. 9/I2/2015 Welcome to the TMB Website I - —— — ‘r—- -71-. .—. —. l _ _. : __/ __ c , , g V . _ . . _'. r.’*. -."'.7-. ..a ,5 - ’( I '_ , . ' ‘‘ _. . ‘__V ‘is ‘ o ' : “_/ h . .' f(. '‘‘. “—' '9'! ‘ _ I ‘: ‘«: j”"I}' 7 . W I‘: I II I F; , . , - ‘- I a 1 / ‘I _ ‘ - "N I I “ ‘ . . ‘ , i 1” . :‘. ‘‘. .’’. ) '. ..J‘ ‘T 7‘ , . : ‘ ’ PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN NAME: ADOLFO CARVAJAL MD DATE: 09/12/2015 THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1948 License Number: J8947 Full Medical License Issuance Date: 12/08/ 1995 Expiration Date of Physician’s Registration Permit: 05/31/2017 Registration Status: ACTIVE Disciplinary Status: NONE Licensure Status: NONE Registration Date: 12/28/1995 Disciplinary Date: NONE Licensure Date: NONE Medical School of Graduation: At the time of licensure, TMB verified the physician’s graduation from medical school as follows: UNIV AUTO DE NUEVO LEON, FAC DE MED, MONTERREY, NUEVO LEON, MEXICO Medical School Graduation Year: 1989 TMB Filings, Actions and License Restrictions The Texas Medical Board has the following board actions against this physician. (This may include any formal complaints filed by TMB, as well as petitions and/ or responses related to licensure contested matters, at the State Office of Administrative Hearings. ) NONE Investigations by TMB of Medical Malpractice Section 164.201 of the Act requires that: the board review information relating to a physician against whom three or more malpractice claims have been reported within a five year period. Based on these reviews, the following investigations were conducted with the listed resolutions. NONE http: //reg. tmb. state. tx. us/ OnLineVcrif/ Phys_ReportVcrif_new . asp I/5
  9. 9. 9/I 2/2()I5 Welcome to the TMB Website Status History Status history contains entries for any updates to the individual's registration, licensure or disciplinary status types (beginning with 1/1/78, when the board’s records were first automated). Entries are in reverse chronological order; new entries of each type supersede the previous entry of that same type. These records do not display status type. Should you have any questions, please contact our Customer Information Center at 512-305-7030 or verifcic@tmb. state. t>_<. us Status Code: AC Effective Date: 12/28/1995 Description: ACTIVE Status Code: Ll Effective Date: 12/08/1995 Description: LICENSE ISSUED THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: MALE Place of Birth: MEXICO Current Primary Practice Address: SOUTH TEXAS RESIDENTIAL FAMILY FACILITY (STRFC) 300 EL RANCHO WAY DILLEY , TX 78017 Years of Active Practice in the U. S. or Canada: The physician reports that he/ she has actively practiced medicine in the United States or Canada for 17 year( ). Years of Active Practice in Texas: The physician reports that, of the above years he/ she has actively practiced in the State of Texas for 8 year(s). Specialty Board Certification The physician reports that he/ she holds the following specialty certifications issued by a board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists: Specialty Certification: AMERICAN BOARD OF FAMILY MEDICINE Date: 1995 Primary Specialty The physician reports his/ her primary practice is in the area of FAMILY PRACTICE. http: //reg. tmb. statc. lx. us/ On LineVeril"/ Ph) s_ReportVeriI‘_ne'. asp
  10. 10. 9/I2/20l5 Welcome to the TMB Website Secondary Specialty The physician did not report a secondary practice area. Name, Location and Graduation Date of All Medical Schools Attended Name: UNIVERSIDAD AUTONOMA DE NUEVO LEON Location: MONTERREY MEXIC Graduation Date: 11/1989 Graduate Medical Education In The United States Or Canada Program Name: COOK COUNTY HOSPITAL Location: CHICAGO, IL Begin Date: 07/1992 Type: RESIDENCY End Date: 07/1995 Specialty: FAMILY PRACTICE Hospital Privileges The physician reports that he/ she has hospital privileges in the following in the State of Texas: NONE Utilization Review The physician did not report whether he/ she provides utilization review. NONE REPORTED Patient Services Accessibility: The physician reports that the patient service area is accessible to persons with disabilities as defined by federal law. Language Translation Services: The physician reports that the following language translation services are provided for patients: SPANISH Medicaid Participant: The physician reports that he/ she does not participate in the Medicaid program. Awards, Honors, Publications and Academic Appointments Optional Information The physician may optionally report descriptions of up to five such honors and has reported the following: http: //rcg. tmb. slate. tx . us/ OnLineVerif/ Phys_ReportVerif_new. asp
  11. 11. 9/I 2/20] 5 Welcome to the TMB Website NONE Malpractice Information Section 154.006(b)(16) of the Act requires that: a physician profile display a description ofany medical malpractice claim against the physician, not including a description of any offers by the physician to settle the claim, for which the physician was found liable, a jury awarded monetary damages to the claimant, and the award has been determined to be final and not subject to further appeal. The physician has the following reportable claims. Description: NONE Criminal History Self-Reported Criminal Offenses: The physician is required to report a description of (1) "any conviction for an offense constituting a felony, a Class A or Class B misdemeanor, or a Class C misdemeanor involving moral turpitude" and (2) "any charges reported to the board to which the physician has pleaded no contest, for which the physician is the subject of deferred adjudication or pretrial diversion, or in which sufficient facts of guilt were found and the matter was continued by a court of competent jurisdiction. " The physician has reported the following: Description: NONE Criminal history information is also obtained by TMB from the Texas Department of Public Safety. Resulting action, if any, will be reported under the TMB Action and Non-Disciplinary Restrictions section above. Disciplinary Actions By Other State Medical Boards The physician has reported the following: Description: NONE To obtain . . . . . Primary Physician Assistant Supervision source verifications, click name Description: NONE To obtain primary http: //reg. tmb. state. t . u.s/ Onl . ineVeriI‘/ Phys_ReportVeril‘_new . zisp
  12. 12. 9/I2/2015 Welcome to the TMB Website Advanced Practice Nurse Delegation = °l{r_¢e , verifications, click name Description: NONE Summary of all LicenselPermit Types Issue Date: Type: 12/08/1995 LICENSED PHYSICIAN 09/11/1995 PHYSICIAN TEMPORARY LICENSE Contact Us I Privacy Policy | Accessibility Policy I Compact with Texans | Website Linking Policy Please contact Pre-Licensure, Registration and Consumer Services at (512) 305-7030 for assistance http: //rcg. tmb. state. tx . us/0nLineVerif/ Phys_ReportVerif_new. asp 5/5
  13. 13. 9/I2/2015 Welcome to the TMB Website TEXAS MEDICAL BOARD PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN ASSISTANT NAME: ELIZABETH VALDIVIA CARMONA PA DATE: 09/12/2015 THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1960 PA License Number: PA04409 Issuance Date: 02/25/2005 Expiration Date: 08/31/2016 Registration Status: ACTIVE Registration Date: 03/28/2005 Disciplinary Status: NONE Disciplinary Date: NONE Licensure Status: NONE Licensure Date: NONE Educafion Year of graduation from physician assistant school: 2004 Program: UNIV OF TEXAS HEALTH SCIENCE CENTER ATSAN ANTONIO Board Action (includes all actions regardless of licenselpermit type) NONE Status History Status history contains entries for any updates to the individual's registration, licensure or disciplinary status types (beginning with 1/1/78, when the board’s records were first automated). Entries are in reverse chronological order; new entries of each type supersede the previous entry of that same type. These records do not display status type. Should you have any questions, please contact our Customer Information Center at 512-305-7030 or verifcic@tmb. state. tx. us Status Code: AC Effective Date: 03/28/2005 Description: ACTIVE Status Code: Ll Effective Date: 02/25/2005 http: //reg. tmb. state. tx . us/ On LineVerif/ Phys__ReportVcril'_new . asp I/2
  14. 14. 9/ I 2/20 I 5 Welcome to the TMB Website Description: LICENSE ISSUED THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: FEMALE Current Primary Practice Address: 300EL RANCHO WAY DILLEY , TX 78017 Active Supervising Physician(s) Note: An asterisk (‘) will appear next to the name of any supervising physician that has an active Board order. Please see the physician’s profile for any information regarding a restriction on prescriptive delegation. Supervising Physician: MILLS, ALICIA E MD License Number: P4893 Begin Date: 01/10/2015 Hours Supervised: 40 Prescriptive Delegation: YES Dangerous Drugs: YES Controlled Substances: YES Summary of all License/ Permit Types Issue Date: Type: 02/25/2005 PHYSICIAN ASSISTANT Contact Us | Privacy Policy | Accessibility Policy j Compact with Texans I Website Linking Policy Please Contact Pre-Licensure. Registration and Consumer Services at (512) 305-7030 for assistance hltp: //reg. tmb. si: Ite. ix . us/ Onl. incVI: rif/ Phys, ReportVerif_IIcw asp 2/2
  15. 15. 9/I2/20|5 Welcome to the TMB Website TEXAS MEDICAL BOARD PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN NAME: ALICIAE MILLS MD DATE:09/12/2015 THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1977 License Number: P4893 Full Medical License Issuance Date: 11/15/2012 Expiration Date of Physician’s Registration Permit: 11/30/2015 Registration Status: ACTIVE Registration Date: 11/26/2012 Disciplinary Status: NONE Disciplinary Date: NONE Licensure Status: NONE Licensure Date: NONE Medical School of Graduation: At the time of licensure, TMB verified the physician’s graduation from medical school as follows: WRIGHT STATE UNIV SCH OF MED, DAYTON Medical School Graduation Year: 2004 TMB Filings, Actions and License Restrictions The Texas Medical Board has the following board actions against this physician. (This may include any formal complaints filed by TMB, as well as petitions and/ or responses related to licensure contested matters, at the State Office of Administrative Hearings. ) NONE Investigations by TMB of Medical Malpractice Section 164.201 of the Act requires that: the board review information relating to a physician against whom three or more malpractice claims have been reported within a five year period. Based on these reviews, the following investigations were conducted with the listed resolutions. NONE http: //reg. tmh: statc. tx . us/ OnLineVerif/ Phys_RcportVcrif_new. asp I /6
  16. 16. 9/I2/20I5 Welcome to the TMB Website Status History Status history contains entries for any updates to the individual’s registration, licensure or disciplinary status types (beginning with 1/1/78, when the board’s records were first automated). Entries are in reverse chronological order; new entries of each type supersede the previous entry of that same type. These records do not display status type. Should you have any questions, please contact our Customer Information Center at 512-305-7030 or verifgig@tmb. §tate. tx. u§ Status Code: AC Effective Date: 11/26/2012 Description: ACTIVE Status Code: Ll Effective Date: 11/15/2012 Description: LICENSE ISSUED THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: FEMALE Current Primary Practice Address: 5815 SILVER SAGE LANE GRAND PRAIRIE , TX 75052 Years of Active Practice in the U. S. or Canada: The physician reports that he/ she has actively practiced medicine in the United States or Canada for 6 year(s). Years of Active Practice in Texas: The physician reports that, of the above years he/ she has actively practiced in the State of Texas for 1 year(s). Specialty Board Certification The physician reports that he/ she holds the following specialty certifications issued by a board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists: Specialty Certification: AMERICAN BOARD OF PEDIATRICS Date: 2007 Primary Specialty The physician reports his/ her primary practice is in the area of PEDIATRICS. http: //reg. tmb. slate. t.‘ . us/ On LincVerif/ Phys_ReportVerif_new . asp
  17. 17. 9/I2/ZOIS Welcome to the TMB Website Secondary Specialty The physician did not report a secondary practice area. Name, Location and Graduation Date of All Medical Schools Attended Name: WRIGHT STATE UNIV SCH OF MED, DAYTON Location: Graduation Date: 05/2004 Graduate Medical Education In The United States Or Canada Program Name: TEXAS TECH HEALTH SCIENCE CENTER Location: LUBBOCK, TX Begin Date: 07/2004 Type: RESIDENCY End Date: 06/2007 Specialty: PEDIATRICS Hospital Privileges The physician reports that he/ she has hospital privileges in the following in the State of Texas: NONE Utilization Review The physician did not report whether he/ she provides utilization review. NONE REPORTED Patient Services Accessibility: The physician reports that the patient service area is accessible to persons with disabilities as defined by federal law. Language Translation Services: The physician reports that the following language translation services are provided for patients: SPANISH Medicaid Participant: The physician reports that he/ she does participate in the Medicaid program. Awards, Honors, Publications and Academic Appointments Optional Information The physician may optionally report descriptions of up to five such honors and has reported the following: http: //reg . tmh. stale. tx . us/ On LineVerif/ Phys_ReportVcrif~nc‘ asp
  18. 18. 9/I 2/ZOIS Welcome to the TMB Wchsitc NONE Malpractice Information Section 154.006(b)(16) of the Act requires that: a physician profile display a description of any medical malpractice claim against the physician, not including a description of any offers by the physician to settle the claim, for which the physician was found liable, a jury awarded monetary damages to the claimant, and the award has been determined to be final and not subject to further appeal. The physician has the following reportable claims. Description: NONE Criminal History Self-Reported Criminal Offenses: The physician is required to report a description of (1) "any conviction for an offense constituting a felony, a Class A or Class B misdemeanor, or a Class C misdemeanor involving moral turpitude" and (2) "any charges reported to the board to which the physician has pleaded no contest, for which the physician is the subject of deferred adjudication or pretrial diversion, or in which sufficient facts of guilt were found and the matter was continued by a court of competent jurisdiction. " The physician has reported the following: Description: NONE Criminal history information is also obtained by TMB from the Texas Department of Public Safety. Resulting action, if any, will be reported under the TMB Action and Non-Disciplinary Restrictions section above. Disciplinary Actions By Other State Medical Boards The physician has reported the following: Description: NONE To obtain . . . . . P”"‘a"Y Physician Assistant Supervision source verifications, click name Physician Assistant Name: CLARK TRACY S PA PA License Number: PA06398 Begin Date: 8/27/2015 Hours Supervised: 40 Prescriptive Delegation: YES http: //rcg. tmh. statc. t . iis/ Onl . incVisril'/ l’hys_RcportVcril'_ncv asp
  19. 19. 9/I2/2015 Welcome to the TMB Website Dangerous Drugs: YES Controlled Substances: YES Physician Assistant Name: CARMONA ELIZABETH VALDIVIA PA PA License Number: PA04409 Begin Date: 1/10/2015 Hours Supervised: 40 Prescriptive Delegation: YES Dangerous Drugs: YES Controlled Substances: YES Physician Assistant Name: IBARRA PETER PA PA License Number: PA08952 Begin Date: 8/3/2015 Hours Supervised: 40 Prescriptive Delegation: YES Dangerous Drugs: YES Controlled Substances: YES Physician Assistant Name: WEAVER DALE J PA License Number: PA01012 Begin Date: 2/15/2015 Hours Supervised: 40 Prescriptive Delegation: YES Dangerous Drugs: YES Controlled Substances: YES Advanced Practice Nurse Delegation APN Name: CQURTEAU, JOAN APN APN License Number: AP109893 Delegation Location Type: Medically Underserved Population Approve Date: 4/25/2015 Hours Supervised: 40 Dangerous Drugs: YES Controlled Substances: YES APN Name: GARCIA VERONICA APN APN License Number: AP106265 Delegation Location Type: Medically Underserved Population Approve Date: 7/6/2015 Illlfti/ /rcg. lmI't. SlillC. l. US/0nI. IIICVCl'If/ I’I1)'S_R€‘p0l'lVCrtI_l1CWJlsp To obtain primary source verifications, click name S/6
  20. 20. 9/| 2/20 I 5 Welcome to the TMB Website Hours Supervised: 40 Dangerous Drugs: YES Controlled Substances: YES APN Name: JALOMO JUANITA APN APN License Number: AP125705 Delegation Location Type: Practice Site Approve Date: 5/26/2015 Hours Supervised: 40 Dangerous Drugs: YES Controlled Substances: YES APN Name: ARMBRECHT, BETTY APN APN License Number: AP112064 Delegation Location Type: Medically Underserved Population Approve Date: 6/16/2015 Hours Supervised: 40 Dangerous Drugs: YES Controlled Substances: YES APN Name: LANEY JARED APN APN License Number: AP123984 Delegation Location Type: Medically Underserved Population Approve Date: 9/1/2015 Hours Supervised: 40 Dangerous Drugs: YES Controlled Substances: YES Summary of all LicenselPermit Types Type: PHYSICIAN IN TRAINING PERMIT LICENSED PHYSICIAN PHYSICIAN TEMPORARY LICENSE Issue Date: 07/01 /2004 11/15/2012 11/01/2012 Contact Us I Privacy Policy I Accessibility Policy | Compact with Texans I Website Linking Policy Please contact Pre—Licensure, Registration and Consumer Services at (512) 305-7030 for assistance. http: //reg . tmb. slatc. t. us/ On LincVcrif/ Pliys_ReportVeril_new . zisp (3/6
  21. 21. 9/I2/20I5 NPI Registry Provider Details . '.' NPPES National Plan 6’. Pro vfder Enumeration System Home He", Back to Results The information for the Provider you selected is displayed. The NPI Registry data was last updated on 09/11/2015. NOTE: Some health care providers reported their SSNs or IRS ITINs in sections of the NPI application that contain information that is required to be disclosed under FOIA. For example, a provider may have reported an SSN or an IRS ITIN as an "Other Provider Identification Number" or as a "License Number". To protect the privacy of these individuals, we have made every attempt to locate and remove those SSNs and IRS ITINs from being displayed in the information provided below. Provider Information: Name: DR. ALICIA E MILLS MD Gender: FEMALE Sole Proprietor: NO NPI Information: NPI: 1700085859 Entity Type: 1-INDIVIDUAL Enumeration Date: 07/17/2007 Last Update Date: 04/17/2015 Replacement NPI: Deactivation Date: Reactivation Date: Provider Business Mailing Address: 1925 WEST HIGHWAY 85 SOUTH TEXAS FAMILY RESIDENTIAL CENTER Ad°"°‘s’ DILLEY, TX 78017 Phone Number: 8303786670 Fax Number: 8303786593 Provider Business Practice Location Address: 1925 WEST HIGHWAY 85 SOUTH TEXAS FAMILY RESIDENTIAL CENTER Add'°°" DILLEY, TX 78017 Phone Number: 8303786670 Fax Number: 8303786593 Provider Taxonomy: Primary Selected Taxonomy State License Number Taxonomy Iillps: //nppcs. CmS. I1hS. g0’/ NPPES Registry/ Disp| ayl’roi'iderDeuii| s.do‘? |asINamc= MiIls+&Iip= &scarchType= ind&npi= I 700085859&city= &orgNamc= &staIc= &Iirst. .. I /2
  22. 22. 9/I2/20l5 NPI Registry Provider Details YES 208000000X - PEDIATRICS OH 35.089897 Other Provider Identifier: Issuer N umber State Issuer OTHER FMO303040 OH DEA Back to Results https: //nppes. cms. hhs. go'/ NPPES Rcgistry/ DispIayPr0viderDetaiIs. d0‘? IastNamc= MilIs+&zip= &scarchType= ind&npi= I 700085859&cit)‘= &orgNamc= &state= &fi rst. .. 2/Z
  23. 23. 9/I2/2015 NPI Registry Provider Details 25.75 / C/ PPES National Plan 6’. Provider Enumeration System Home He“, Back to Results The information for the Provider you selected is displayed. The NPI Registry data was last updated on 09/11/2015. NOTE: Some health care providers reported their SSNs or IRS | TINs in sections of the NPI application that contain information that is required to be disclosed under FOIA. For example, a provider may have reported an SSN or an IRS ITIN as an "Other Provider Identification Number" or as a "License Number“. To protect the privacy of these individuals, we have made every attempt to locate and remove those SSNs and IRS | TINs from being displayed in the information provided below. Provider Information: Name: AN NGUYEN PHARM. D Gender: MALE Sole Proprietor: YES NPI Information: NPI: 1649677519 Entity Type: 1-INDIVIDUAL Enumeration Date: 11/20/2014 Last Update Date: 11 /20/2014 Replacement NPI: Deactivation Date: Reactivation Date: Provider Business Mailing Address: _ 8907 WESTWILLOW DR A"‘"°“' HOUSTON, TX 77064-8891 Phone Number: 8328597787 Fax Number: Provider Business Practice Location Address: 1925 WEST HIGHWAY 85 Add’°”‘ DILLEY, TX 78017 Phone Number: 2108384109 Fax Number: Provider Taxonomy: Primary Selected Taxonomy State License Number Taxonomy https: //nppcs. cms. hhs. gov/ NPPESRegistry/ Disp| ayProvidcrl)ctaiIs. do? IastName= &zip=780l 7&scarchType= ind&npi= I 6496775 I 9&city= &orgName= &statc= TX&fi. .. I/2
  24. 24. 9/I2/20I5 NPI Registry Provider Details YES 183500000X - PHARMACIST TX 53952 Other Provider Identifier: Issuer Number State Issuer Back to Results https: //nppcs. cms. hhs. go‘/ NPPESRegistry/ DispIayProviderDctai| s.do? |astName: &zip=780 I 7&scarch'I‘ype= ind&npi= I 6496775 I 9&cily= &orgName= &state= TX&fi. .. 2/2
  25. 25. 9/ I 2/20l5 ’"‘ I Welcome to the TMB Website __. ‘ __, ,, I ‘. __. - : _.. ».. »-. «.’-:4 KAI 3.‘_*. ‘3.«. ”?J‘1.T "L-‘-".85 '_'~2:o. :'. :.: z:. PUBLIC VERIFICATION I PHYSICIAN PROFILE PHYSICIAN NAME: KEITH ALLAN FISHER MD DATE:09/12/2015 THE INFORMATION IN THIS BOX HAS BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Date of Birth: 1975 License Number: M2321 Full Medical License Issuance Date: 10/07/2005 Expiration Date of Physician’s Registration Permit: 08/31/2017 Registration Date: 11/03/2005 Disciplinary Date: NONE Licensure Date: NONE Registration Status: ACTIVE Disciplinary Status: NONE Licensure Status: NONE Medical School of Graduation: At the time of licensure, TMB verified the physician’s graduation from medical school as follows: HAHNEMANN UNIV SCH OF MED, PHILADELPHIA (AFTER 2002 USE 4115) Medical School Graduation Year: 2001 TMB Filings, Actions and License Restrictions The Texas Medical Board has the following board actions against this physician. (This may include any formal complaints filed by TMB, as well as petitions and/ or responses related to licensure contested matters, at the State Office of Administrative Hearings. ) NONE Investigations by TMB of Medical Malpractice Section 164.201 of the Act requires that: the board review information relating to a physician against whom three or more malpractice claims have been reported within a five year period. Based on these reviews, the following investigations were conducted with the listed resolutions. NONE httpr/ /rcg. Imb. state. lx . us/0nLineVerif/ Phys_RcportVeril'_newasp I/5
  26. 26. 9/I2/2015 Welcome to the TMB Website Status History Status history contains entries for any updates to the individual's registration, licensure or disciplinary status types (beginning with 1/1/78, when the board’s records were first automated). Entries are in reverse chronological order; new entries of each type supersede the previous entry of that same type. These records do not display status type. Should you have any questions, please contact our Customer Information Center at 512-305-7030 or verifcic@1;mb. state. tx. us Status Code: AC Effective Date: 11/03/2005 Description: ACTIVE Status Code: Ll Effective Date: 10/07/2005 Description: LICENSE ISSUED THE INFORMATION IN THIS BOX WAS REPORTED BY THE LICENSEE AND HAS NOT BEEN VERIFIED BY THE TEXAS MEDICAL BOARD Gender: MALE Current Primary Practice Address: 11124 WURZBACH RD SUITE 206 SAN ANTONIO , TX 78230 Years of Active Practice in the U. S. or Canada: The physician reports that he/ she has actively practiced medicine in the United States or Canada for 10 year(s). Years of Active Practice in Texas: The physician reports that, of the above years he/ she has actively practiced in the State of Texas for 10 year(s). Specialty Board Certification The physician reports that he/ she holds the following specialty certifications issued by a board that is a member of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists: Specialty Certification: AMERICAN BOARD OF PSYCHIATRY & NEUROLOGY/ PSYCHIATRY Date: 2006 Primary Specialty http: //rcg. tmb. sta1e. tx . us/ OnLineVerif/ PIiys_ReportVcrif_new . asp 2/5
  27. 27. 9/I2/20l5 Welcome to the TMB Website The physician reports his/ her primary practice is in the area of PSYCHIATRY. Secondary Specialty The physician did not report a secondary practice area. Name, Location and Graduation Date of All Medical Schools Attended Name: HAHNEMANN UNIV SCH OF MED, PHILADELPHIA (AFTER 2002 USE 4115) Location: Graduation Date: 05/2001 Graduate Medical Education In The United States Or Canada Program Name: SAUSHEC Location: SAN ANTONIO Begin Date: 07/2001 Type: INTERNSHIP End Date: 6/2002 Specialty: PSYCHIATRY Program Name: UTHSCSA Location: SAN ANTONIO Begin Date: 7/2001 Type: RESIDENCY End Date: 6/2005 Specialty: PSYCHIATRY Hospital Privileges The physician reports that he/ she has hospital privileges in the following in the State of Texas: NONE Utilization Review The physician did not report whether he/ she provides utilization review. NONE REPORTED Patient Services Accessibility: The physician reports that the patient service area is accessible to persons with disabilities as defined by federal law. Language Translation Services: The physician did not report whether he/ she provided any language translation services for patients. Medicaid Participant: The physician reports that he/ she does not participate in the Medicaid program. http: //rcg. tmb. statc. tx . us/ On! .ineVcril‘/ Phys_ReportVerit'_ne' asp 3/5
  28. 28. 9/I2/20I5 Welcome to the TMB Website Awards, Honors, Publications and Academic Appointments Optional Information The physician may optionally report descriptions of up to five such honors and has reported the following: Description: CLINICAL ASSISTANT PROFESSOR OF PSYCHIATRY, UTHSCSA Malpractice Information Section 154.006(b)(16) of the Act requires that: a physician profile display a description of any medical malpractice claim against the physician, not including a description of any offers by the physician to settle the claim, for which the physician was found liable, a jury awarded monetary damages to the claimant, and the award has been determined to be final and not subject to further appeal. The physician has the following reportable claims. Description: NONE Criminal History Self-Reported Criminal Offenses: The physician is required to report a description of (1) "any conviction for an offense constituting a felony, a Class A or Class B misdemeanor, or a Class C misdemeanor involving moral turpitude" and (2) "any charges reported to the board to which the physician has pleaded no contest, for which the physician is the subject of deferred adjudication or pretrial diversion, or in which sufficient facts of guilt were found and the matter was continued by a court of competent jurisdiction. " The physician has reported the following: Description: NONE Criminal history information is also obtained by TMB from the Texas Department of Public Safety. Resulting action, if any, will be reported under the TMB Action and Non-Disciplinary Restrictions section above. Disciplinary Actions By Other State Medical Boards The physician has reported the following: Description: NONE To obtain primary Physician Assistant Supervision source verifications, click name http: //reg . tmb. statc. tx. us/ OnLincVcri1'/ Phys_ReportVcril‘_ncw . asp
  29. 29. 9/12/20I5 Welcome to the TMB Website Description: NONE Advanced Practice Nurse Delegation Description: NONE Summary of all LicenselPermit Types Issue Date: 07/01/2001 07/12/2002 09/12/2003 03/12/2005 10/07/2005 08/16/2005 07/01/2001 Type: PHYSICIAN IN TRAINING PERMIT PHYSICIAN IN TRAINING PERMIT PHYSICIAN IN TRAINING PERMIT PHYSICIAN IN TRAINING PERMIT LICENSED PHYSICIAN PHYSICIAN TEMPORARY LICENSE PHYSICIAN IN TRAINING PERMIT To obtain primary source verifications, click name Contact Us | Privacy Policy | Accessibility Policy | Compact with Texans | Website Linking Policy Please contact Pre-Licensure. Registration and Consumer Sen/ ices at (512) 305-7030 for assistance, hlip: //rcg. lmb. state. t. us/ OnLincVerif/ Phys_RepnnVerif_ne‘. asp 5/5

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