Provider Demographics
NPI:1336725936
Name:WOOD, ELIJAH CAMILO
Entity Type:Individual
Prefix:
First Name:ELIJAH
Middle Name:CAMILO
Last Name:WOOD
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 1:113 GREEN OAKS CT
Mailing Address - Street 2:
Mailing Address - City:HUDSON OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76087-8900
Mailing Address - Country:US
Mailing Address - Phone:210-569-3941
Mailing Address - Fax:
Practice Address - Street 1:113 GREEN OAKS CT
Practice Address - Street 2:
Practice Address - City:HUDSON OAKS
Practice Address - State:TX
Practice Address - Zip Code:76087-8900
Practice Address - Country:US
Practice Address - Phone:210-569-3941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14332363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical