Healthcare Provider Details

I. General information

NPI: 1629756986
Provider Name (Legal Business Name): MERCIFUL EKONGMADEM EYONGEGBE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/15/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 W TERRELL AVE
FORT WORTH TX
76104-3161
US

IV. Provider business mailing address

PO BOX 33434
FORT WORTH TX
76162-3434
US

V. Phone/Fax

Practice location:
  • Phone: 817-756-7385
  • Fax: 817-332-1723
Mailing address:
  • Phone: 817-332-8346
  • Fax: 817-332-1723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16986
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: