1063971588 NPI number — EMMANUEL AGHOGHOVWIA MUKORO PTA

Table of content: EMMANUEL AGHOGHOVWIA MUKORO PTA (NPI 1063971588)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063971588 NPI number — EMMANUEL AGHOGHOVWIA MUKORO PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUKORO
Provider First Name:
EMMANUEL
Provider Middle Name:
AGHOGHOVWIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063971588
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
931 WINDY GARDEN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77406-7218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4771 SWEETWATER BLVD
Provider Second Line Business Practice Location Address:
SUITE 179
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-265-5359
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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