Provider Demographics
NPI:1194473439
Name:WEMBOLENGA, PAUL OKITANGOLO
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:OKITANGOLO
Last Name:WEMBOLENGA
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 1:24306 MERLIN ROOST CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-4816
Mailing Address - Country:US
Mailing Address - Phone:346-297-0588
Mailing Address - Fax:
Practice Address - Street 1:15000 BELLAIRE BLVD STE 0
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-2536
Practice Address - Country:US
Practice Address - Phone:713-371-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20902353172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver