Provider Demographics
NPI:1134433113
Name:MBOLA, STEPHEN M (ANP)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:MBOLA
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8511 S SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77075-4874
Mailing Address - Country:US
Mailing Address - Phone:713-343-2301
Mailing Address - Fax:
Practice Address - Street 1:2626 S LOOP W STE 265
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-5636
Practice Address - Country:US
Practice Address - Phone:713-796-9955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX666178363LA2200X
TXAP117709363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217286803Medicaid
TX217286803Medicaid