Provider Demographics
NPI:1023456134
Name:MOGOTSAKGOTLA, LEBAONE LLULU (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:LEBAONE
Middle Name:LLULU
Last Name:MOGOTSAKGOTLA
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 BENTWORTH DR APT 440
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-6220
Mailing Address - Country:US
Mailing Address - Phone:713-562-8305
Mailing Address - Fax:
Practice Address - Street 1:2020 BENTWORTH DR APT 440
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-6220
Practice Address - Country:US
Practice Address - Phone:713-562-8305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP123544363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327062101Medicaid
TX327062101Medicaid