Provider Demographics
NPI:1558493965
Name:NWAFOR, VITUS UCHENNA (PA)
Entity Type:Individual
Prefix:MR
First Name:VITUS
Middle Name:UCHENNA
Last Name:NWAFOR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 EASTLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0738
Mailing Address - Country:US
Mailing Address - Phone:469-279-4088
Mailing Address - Fax:
Practice Address - Street 1:2740 EASTLAND DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0738
Practice Address - Country:US
Practice Address - Phone:469-279-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04037OtherMEDICAL LICENSE