Provider Demographics
NPI:1689203853
Name:KWOWI, NELSON JONG
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:JONG
Last Name:KWOWI
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 1:5904 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8768
Mailing Address - Country:US
Mailing Address - Phone:325-320-0414
Mailing Address - Fax:
Practice Address - Street 1:5121 BLUE ROSE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-2678
Practice Address - Country:US
Practice Address - Phone:469-490-1505
Practice Address - Fax:469-490-1516
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX888347163W00000X
TX1019811363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse