Provider Demographics
NPI:1407232341
Name:MUKETIWA, SIMBA K
Entity Type:Individual
Prefix:
First Name:SIMBA
Middle Name:K
Last Name:MUKETIWA
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 1:104 PARKHURST LANE
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013
Mailing Address - Country:US
Mailing Address - Phone:469-688-3437
Mailing Address - Fax:
Practice Address - Street 1:104 PARKHURST LANE
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013
Practice Address - Country:US
Practice Address - Phone:469-688-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129372363LA2100X
TX732024163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care