Provider Demographics
NPI:1235288002
Name:WILMOT, LUIS JR (PA)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:WILMOT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 NIAGARA HTS
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-8279
Mailing Address - Country:US
Mailing Address - Phone:210-722-9863
Mailing Address - Fax:
Practice Address - Street 1:600 ROUND ROCK WEST DR STE 703
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5005
Practice Address - Country:US
Practice Address - Phone:512-919-4481
Practice Address - Fax:512-919-4485
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1070763OtherNCCPA CERTIFICATION