Provider Demographics
NPI:1649387630
Name:EFEOVBOKHAN, UGHANMWAN (NP)
Entity Type:Individual
Prefix:
First Name:UGHANMWAN
Middle Name:
Last Name:EFEOVBOKHAN
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 1:8101 ROUGHRIDER DR
Mailing Address - Street 2:
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78239-2428
Mailing Address - Country:US
Mailing Address - Phone:210-657-3700
Mailing Address - Fax:210-657-3700
Practice Address - Street 1:8101 ROUGHRIDER DR
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78239-2428
Practice Address - Country:US
Practice Address - Phone:210-657-3700
Practice Address - Fax:210-657-3708
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX683669363LG0600X
TXAP113326363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167293301Medicaid
TX167293301Medicaid
TX8C1708Medicare PIN