Organization
BRAZOSPORT COMMUNITY MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. INYANG E WILSON PA (CEO/PA)
(979) 871-9453
Entity
Organization
Contact information
Practice address
606 N GULF BLVD, FREEPORT, TX 77541-3902
(979) 871-9453
(979) 871-9429
Mailing address
606 N GULF BLVD, FREEPORT, TX 77541-3902
(979) 871-9453
(979) 871-9429
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
PA00933
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
138038816
—
TX
05
—
162136901
—
TX
Enumeration date
05/22/2006
Last updated
05/04/2015
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