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General NPI Number Information
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NPI Number | 1871117135
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Entity Type | Individual
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Provider Name | MAX WILMOT PHYSICIAN ASSISTANT
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Gender | Male
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Dates
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Enumeration Date | 06/02/2020
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Last Update Date | 06/23/2022
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Provider Practice Location Address
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Address Line | 6621 FANNIN ST
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City | HOUSTON
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State | TX
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Zip | 77030-2399
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Country | US
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Telephone | 832-822-4602
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Fax |
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Provider Business Mailing Address
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Address Line | 4100 GREENBRIAR DR APT 463
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City | HOUSTON
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State | TX
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Zip | 77098-5539
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Country | US
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Telephone | 404-862-6033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 0010-10046
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA15725
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License Number State | TX
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