Provider Demographics
NPI:1679795900
Name:NJOTU, MICHAEL ANDA (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDA
Last Name:NJOTU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 DELAFORD DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-3859
Mailing Address - Country:US
Mailing Address - Phone:817-793-4571
Mailing Address - Fax:
Practice Address - Street 1:4010 E BELKNAP ST
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76111-6609
Practice Address - Country:US
Practice Address - Phone:817-831-4300
Practice Address - Fax:817-831-4306
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP93457Medicare UPIN