Provider Demographics
NPI:1669109666
Name:NKWAIN, MARY PHUBONG
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PHUBONG
Last Name:NKWAIN
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 1:5788 ECKHERT RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3900
Mailing Address - Country:US
Mailing Address - Phone:210-450-6450
Mailing Address - Fax:
Practice Address - Street 1:8535 TOM SLICK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3367
Practice Address - Country:US
Practice Address - Phone:210-616-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1093159363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty