Healthcare Provider Details

I. General information

NPI: 1144555251
Provider Name (Legal Business Name): PROVIDENCE NEUROLOGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W HILLSIDE RD SUITE 5 B
LAREDO TX
78041-6903
US

IV. Provider business mailing address

220 W HILLSIDE RD SUITE 5 B
LAREDO TX
78041-6903
US

V. Phone/Fax

Practice location:
  • Phone: 956-717-4074
  • Fax: 956-717-4186
Mailing address:
  • Phone: 956-717-4074
  • Fax: 956-717-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberN3913
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberN3913
License Number StateTX

VIII. Authorized Official

Name: DR. GRACE MUKAMANA
Title or Position: MD/OWNER
Credential: MD
Phone: 956-717-4074