Provider Demographics
NPI:1326256348
Name:MUKAMANA, GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:MUKAMANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 VILLAGE DR STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-5419
Mailing Address - Country:US
Mailing Address - Phone:210-655-3800
Mailing Address - Fax:210-655-3801
Practice Address - Street 1:8715 VILLAGE DR STE 418
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5407
Practice Address - Country:US
Practice Address - Phone:210-655-3800
Practice Address - Fax:210-655-3801
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN39132084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210192501Medicaid
TX210192501Medicaid