Healthcare Provider Details

I. General information

NPI: 1871166421
Provider Name (Legal Business Name): SAMUEL NYAWANSA GWAYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 LAKE HAVEN LN
DENTON TX
76208-2055
US

IV. Provider business mailing address

2224 LAKE HAVEN LN
DENTON TX
76208-2055
US

V. Phone/Fax

Practice location:
  • Phone: 682-554-3270
  • Fax:
Mailing address:
  • Phone: 682-554-3270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1048011
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: