Provider Demographics
NPI:1770135576
Name:OSAKWE, SHADIA
Entity type:Individual
Prefix:
First Name:SHADIA
Middle Name:
Last Name:OSAKWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHADIA
Other - Middle Name:
Other - Last Name:EISSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:855 MONTGOMERY STREET,
Mailing Address - Street 2:PEDIATRIC CLINIC
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-735-0349
Mailing Address - Fax:817-735-2653
Practice Address - Street 1:855 MONTGOMERY STREET,
Practice Address - Street 2:PEDIATRIC CLINIC
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-735-0349
Practice Address - Fax:817-735-2653
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-6064033Medicaid