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Organization
SHEPHERD RURAL HEALTH CLINIC PA
Active
Organization
SHEPHERD RURAL HEALTH CLINIC PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. PHILIP R WISIACKAS MD (PHYSICIAN)
(936) 628-3343
Entity
Organization
Contact information
Practice address
11 WOODLAND PARK DRIVE, SHEPHERD, TX 77371
(936) 628-3343
Mailing address
PO BOX 669, SHEPHERD, TX 77371-0669
(936) 628-3343
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
F4703
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
130767003
—
TX
Enumeration date
10/31/2006
Last updated
08/30/2010
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