Provider Demographics
NPI:1881231637
Name:ANIAGOH, OKECHUKWU (PA)
Entity Type:Individual
Prefix:
First Name:OKECHUKWU
Middle Name:
Last Name:ANIAGOH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 REGENCY PKWY STE 405
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5169
Mailing Address - Country:US
Mailing Address - Phone:682-518-1100
Mailing Address - Fax:
Practice Address - Street 1:305 REGENCY PKWY STE 405
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5169
Practice Address - Country:US
Practice Address - Phone:682-518-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-27
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13286363A00000X
FLPA9112770363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant