Provider Demographics
NPI:1871117135
Name:WILMOT, MAX (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:WILMOT
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 GREENBRIAR DR APT 463
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-5539
Mailing Address - Country:US
Mailing Address - Phone:404-862-6033
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2399
Practice Address - Country:US
Practice Address - Phone:832-822-4602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10046208000000X
TXPA15725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics