Provider Demographics
NPI:1255023859
Name:MUSHURA, GRATIOUS NYASHA
Entity type:Individual
Prefix:MR
First Name:GRATIOUS
Middle Name:NYASHA
Last Name:MUSHURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 BERKSHIRE RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-1624
Mailing Address - Country:US
Mailing Address - Phone:615-635-2789
Mailing Address - Fax:
Practice Address - Street 1:3317 BERKSHIRE RD NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-1624
Practice Address - Country:US
Practice Address - Phone:615-635-2789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54756163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation