Healthcare Provider Details

I. General information

NPI: 1053080580
Provider Name (Legal Business Name): WIGDAN HASSAN AHMED MOHAMMED NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HARBORSIDE DR STE 103
GALVESTON TX
77555-5003
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265-5003
US

V. Phone/Fax

Practice location:
  • Phone: 409-772-3695
  • Fax:
Mailing address:
  • Phone: 409-747-6240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1019667
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: