Provider Demographics
NPI:1629756986
Name:EYONGEGBE, MERCIFUL EKONGMADEM (PA-C)
Entity Type:Individual
Prefix:
First Name:MERCIFUL
Middle Name:EKONGMADEM
Last Name:EYONGEGBE
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:PO BOX 33434
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-3434
Mailing Address - Country:US
Mailing Address - Phone:817-332-8346
Mailing Address - Fax:817-332-1723
Practice Address - Street 1:851 W TERRELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3161
Practice Address - Country:US
Practice Address - Phone:817-756-7385
Practice Address - Fax:817-332-1723
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16986363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty