Provider Demographics
NPI:1790274074
Name:ENUDU, FERDINAND EKWUTOSI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:FERDINAND
Middle Name:EKWUTOSI
Last Name:ENUDU
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 OLD AGENCY DR UNIT 138
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7227
Mailing Address - Country:US
Mailing Address - Phone:713-478-5660
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-698-7606
Practice Address - Fax:651-431-7462
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137180363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner