Healthcare Provider Details

I. General information

NPI: 1346720307
Provider Name (Legal Business Name): SHAUKAT ALI KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 VILLAGE RD
PORT LAVACA TX
77979-2380
US

IV. Provider business mailing address

524 VILLAGE RD
PORT LAVACA TX
77979-2380
US

V. Phone/Fax

Practice location:
  • Phone: 361-552-3741
  • Fax:
Mailing address:
  • Phone: 361-552-3741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License Number102584
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: