Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 102584 | TX |
NPI | 1346720307 |
---|---|
Provider Name | Shaukat Ali Khan |
First Address | Port Lavaca, TX 77979-2380 |
Second Address | Port Lavaca, TX 77979-2380 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2018 |
Last Update Date | 20/08/2018 |