Healthcare Provider Details

I. General information

NPI: 1679067615
Provider Name (Legal Business Name): MARCEL IKENNA CHUKWU NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9234 N LOOP 1604 W STE 107
SAN ANTONIO TX
78249-2981
US

IV. Provider business mailing address

9234 N LOOP 1604 W STE 107
SAN ANTONIO TX
78249-2981
US

V. Phone/Fax

Practice location:
  • Phone: 210-963-7398
  • Fax: 210-963-8512
Mailing address:
  • Phone: 210-963-7398
  • Fax: 210-963-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP133122
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: