Provider Demographics
NPI:1184881013
Name:SHELDON EXTRACARE FAMILY PRACTICE
Entity type:Organization
Organization Name:SHELDON EXTRACARE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:LATINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:281-458-4707
Mailing Address - Street 1:8514 C E KING PKWY
Mailing Address - Street 2:SUITE T
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77044-2344
Mailing Address - Country:US
Mailing Address - Phone:281-458-4707
Mailing Address - Fax:281-458-4700
Practice Address - Street 1:8514 C E KING PKWY
Practice Address - Street 2:SUITE T
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77044-2344
Practice Address - Country:US
Practice Address - Phone:281-458-4707
Practice Address - Fax:281-458-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4259261Q00000X
TXPA03060261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center