Provider Demographics
NPI:1700391257
Name:WAGONEKA, PAIDAMOYO YVONNE
Entity Type:Individual
Prefix:
First Name:PAIDAMOYO
Middle Name:YVONNE
Last Name:WAGONEKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 HIGHWAY 287 N # 1071
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4807
Mailing Address - Country:US
Mailing Address - Phone:817-400-0433
Mailing Address - Fax:817-415-6595
Practice Address - Street 1:1771 HIGHWAY 287 N # 1071
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4807
Practice Address - Country:US
Practice Address - Phone:817-400-0433
Practice Address - Fax:817-415-6595
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily