Provider Demographics
NPI:1760927172
Name:ABRAHAM, DEEPA TONY
Entity Type:Individual
Prefix:
First Name:DEEPA
Middle Name:TONY
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEEPA
Other - Middle Name:
Other - Last Name:KOCHETHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:10416 HOLLYHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-7517
Mailing Address - Country:US
Mailing Address - Phone:405-371-8891
Mailing Address - Fax:
Practice Address - Street 1:609 HEMPHILL ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3149
Practice Address - Country:US
Practice Address - Phone:817-923-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK95153163W00000X
TXAP133659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty