Provider Demographics
NPI:1578748505
Name:MWANGI, JOHNSON N (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNSON
Middle Name:N
Last Name:MWANGI
Suffix:
Gender:M
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 1:5310 HARVEST HILL RD STE 290
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-5826
Mailing Address - Country:US
Mailing Address - Phone:214-420-0650
Mailing Address - Fax:
Practice Address - Street 1:1720 S BECKHAM AVE STE 102
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4437
Practice Address - Country:US
Practice Address - Phone:903-618-2125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA011035363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44155301Medicaid