Healthcare Provider Details

I. General information

NPI: 1407232341
Provider Name (Legal Business Name): SIMBA K MUKETIWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PARKHURST LANE
ALLEN TX
75013
US

IV. Provider business mailing address

104 PARKHURST LANE
ALLEN TX
75013
US

V. Phone/Fax

Practice location:
  • Phone: 469-688-3437
  • Fax:
Mailing address:
  • Phone: 469-688-3437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP129372
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: