Provider Demographics
NPI:1386978864
Name:AGWU, HENDRICKS
Entity type:Individual
Prefix:
First Name:HENDRICKS
Middle Name:
Last Name:AGWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7240 ROBLE
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0100
Mailing Address - Country:US
Mailing Address - Phone:347-247-2959
Mailing Address - Fax:
Practice Address - Street 1:105 KATHRYN DR BLDG 3
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4216
Practice Address - Country:US
Practice Address - Phone:800-972-0643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-30
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1052379363LP0808X
WAAP61183839363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health