Provider Demographics
NPI:1124518253
Name:UDO, ENOBONG C (A-GNP)
Entity type:Individual
Prefix:
First Name:ENOBONG
Middle Name:C
Last Name:UDO
Suffix:
Gender:F
Credentials:A-GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-7826
Mailing Address - Country:US
Mailing Address - Phone:214-590-0409
Mailing Address - Fax:214-590-0413
Practice Address - Street 1:2231 BUTLER ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7826
Practice Address - Country:US
Practice Address - Phone:214-590-0409
Practice Address - Fax:214-590-0413
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137519363LA2200X, 363LG0600X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care