Provider Demographics
NPI:1851852677
Name:BISONG, GWENDOLYN
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BISONG
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 1:13700 VETERANS MEMORIAL DR STE 235
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-1026
Mailing Address - Country:US
Mailing Address - Phone:281-508-4466
Mailing Address - Fax:832-218-9001
Practice Address - Street 1:13700 VETERANS MEMORIAL DR STE 235
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-1026
Practice Address - Country:US
Practice Address - Phone:281-508-4466
Practice Address - Fax:832-218-9001
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty