Provider Demographics
NPI:1194342063
Name:AGWATA, GEOFFREY NYANARO (APRN)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:NYANARO
Last Name:AGWATA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 GLADIOLA CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2139
Mailing Address - Country:US
Mailing Address - Phone:903-805-4281
Mailing Address - Fax:
Practice Address - Street 1:4704 GLADIOLA CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2139
Practice Address - Country:US
Practice Address - Phone:903-805-4281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX808206163W00000X
390200000X
TX1045065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program