Provider Demographics
NPI:1790376598
Name:PULICKATHOTTIYIL, SELVIN JOSE
Entity Type:Individual
Prefix:
First Name:SELVIN
Middle Name:JOSE
Last Name:PULICKATHOTTIYIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 KING COTTON LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-4240
Mailing Address - Country:US
Mailing Address - Phone:832-566-8670
Mailing Address - Fax:
Practice Address - Street 1:18200 KATY FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77094-1285
Practice Address - Country:US
Practice Address - Phone:832-566-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant