Provider Demographics
NPI:1659026680
Name:EZEKWESILI, KIM IKE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:IKE
Last Name:EZEKWESILI
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 1:24818 PLEASANT SHORES CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-1682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6720 BERTNER AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2604
Practice Address - Country:US
Practice Address - Phone:832-355-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856879367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered