MEDICARE: WANDA ELLIOTT LSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	SA00037	TX

General Provider Information

NPI Number	:	1902848070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA ELLIOTT LSA

Provider Business Mailing Address
First Line	:	6400 FANNIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-1521
Country	:	US
Telephone Number	:	713-867-4004
Fax Number	:	281-359-2811

Provider Business Practice Location Address
First Line	:	601 ROCKMEAD DR
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77339-2107
Country	:	US
Telephone Number	:	713-486-7400
Fax Number	:	281-359-2811

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	06/10/2022

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Directions to “ WANDA ELLIOTT LSA” Practice Location

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