Provider Demographics
NPI:1881474740
Name:EZIEKE, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:EZIEKE
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 1:2808 GRANTS LAKE BLVD UNIT 302
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1345
Mailing Address - Country:US
Mailing Address - Phone:832-600-4490
Mailing Address - Fax:
Practice Address - Street 1:2808 GRANTS LAKE BLVD UNIT 302
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-1345
Practice Address - Country:US
Practice Address - Phone:832-600-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1130660363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily