Provider Demographics
NPI:1558094029
Name:BOTOMANI-MPOSI, MAYA MIKO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:MIKO
Last Name:BOTOMANI-MPOSI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7560 WATERPOINT ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0170
Mailing Address - Country:US
Mailing Address - Phone:817-917-0516
Mailing Address - Fax:
Practice Address - Street 1:7560 WATERPOINT ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75054-0170
Practice Address - Country:US
Practice Address - Phone:817-917-0516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program