Provider Demographics
NPI:1689122574
Name:EZEUKA, UZOMA I
Entity Type:Individual
Prefix:
First Name:UZOMA
Middle Name:I
Last Name:EZEUKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:UZOMA
Other - Middle Name:I
Other - Last Name:UDOMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6551 HARRIS PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6105
Mailing Address - Country:US
Mailing Address - Phone:817-625-3500
Mailing Address - Fax:682-708-7225
Practice Address - Street 1:6551 HARRIS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6105
Practice Address - Country:US
Practice Address - Phone:817-625-3500
Practice Address - Fax:682-708-7225
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC221165163WP2201X
SC20714363LF0000X
TXAP137572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX409078901Medicaid
SCNP4499Medicaid