Provider Demographics
NPI:1376774869
Name:MADU, RENITA (PA)
Entity Type:Individual
Prefix:MS
First Name:RENITA
Middle Name:
Last Name:MADU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12004 SHADOW CREEK PKWY
Mailing Address - Street 2:SUITE 121
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7326
Mailing Address - Country:US
Mailing Address - Phone:281-968-9290
Mailing Address - Fax:281-463-1432
Practice Address - Street 1:12004 SHADOW CREEK PKWY
Practice Address - Street 2:SUITE 121
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7326
Practice Address - Country:US
Practice Address - Phone:281-968-9290
Practice Address - Fax:281-463-1432
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA05780363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111687302Medicaid