Provider Demographics
NPI:1629578406
Name:MAINA, EDWARD M
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:MAINA
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 1:1113 SWITCHGRASS LN
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1113 SWITCHGRASS LN
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4318
Practice Address - Country:US
Practice Address - Phone:940-594-7761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX873703163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse