Provider Demographics
NPI:1548779234
Name:OMWENGA, STRAVENS MOSETI
Entity Type:Individual
Prefix:
First Name:STRAVENS
Middle Name:MOSETI
Last Name:OMWENGA
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 1:3909 RUTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-7785
Mailing Address - Country:US
Mailing Address - Phone:469-733-2200
Mailing Address - Fax:
Practice Address - Street 1:271 FORT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AFB
Practice Address - State:TX
Practice Address - Zip Code:76908-4901
Practice Address - Country:US
Practice Address - Phone:325-654-3149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty