Provider Demographics
NPI:1215401906
Name:AHEDOR, PRINCESS KUKUA
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:KUKUA
Last Name:AHEDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 RIO BRAVO ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1054
Mailing Address - Country:US
Mailing Address - Phone:915-532-0010
Mailing Address - Fax:915-532-0012
Practice Address - Street 1:1600 MEDICAL CENTER DR STE 400
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5008
Practice Address - Country:US
Practice Address - Phone:915-217-2163
Practice Address - Fax:915-217-2166
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
TXAP139886363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily