Provider Demographics
NPI:1073087805
Name:MORA, KOSISOCHUKWU (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:KOSISOCHUKWU
Middle Name:
Last Name:MORA
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 ROLLING HILLS LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-7076
Mailing Address - Country:US
Mailing Address - Phone:214-334-8117
Mailing Address - Fax:
Practice Address - Street 1:1617 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4709
Practice Address - Country:US
Practice Address - Phone:817-702-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant