Provider Demographics
NPI:1629540497
Name:NGISHU, SIMEON (NP)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:
Last Name:NGISHU
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MISTLETOE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4048
Mailing Address - Country:US
Mailing Address - Phone:817-338-1300
Mailing Address - Fax:817-335-9871
Practice Address - Street 1:1900 MISTLETOE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4048
Practice Address - Country:US
Practice Address - Phone:817-338-1300
Practice Address - Fax:817-335-9871
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139942363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX394063701Medicaid