Healthcare Provider Details

I. General information

NPI: 1750009148
Provider Name (Legal Business Name): JOSEPH MOKOUBA-SONY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 FANNIN ST
HOUSTON TX
77030-2358
US

IV. Provider business mailing address

6621 FANNIN ST
HOUSTON TX
77030-2358
US

V. Phone/Fax

Practice location:
  • Phone: 832-824-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18660
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: