=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265809768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IKENNA SAMUEL UZOCHUKWU NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2015
-----------------------------------------------------
Last Update Date | 09/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3604 BUDDY OWENS AVE
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-213-8494
-----------------------------------------------------
Fax | 956-213-8492
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2931 LAKE SHORE HARBOUR DR
-----------------------------------------------------
City | MISSOURI CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77459-7623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-204-1954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | K6377
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------