MEDICARE: MRS. NADINE NZENGA UDOM FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	AP133480	TX
2	363L00000X	Nurse Practitioner	AP133480	TX
3	207Q00000X	Family Medicine Physician	AP133480	TX

General Provider Information

NPI Number	:	1063941060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NADINE NZENGA UDOM FNP

Provider Business Mailing Address
First Line	:	5460 BABCOCK RD STE 120-C
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78240-3901
Country	:	US
Telephone Number	:	940-395-8333
Fax Number	:	210-783-8444

Provider Business Practice Location Address
First Line	:	10323 STATE HIGHWAY 151
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4557
Country	:	US
Telephone Number	:	210-581-5306
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	07/26/2023

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