Provider Demographics
NPI:1427607696
Name:AGHO, RUKEVWE THEODORA (NP)
Entity type:Individual
Prefix:
First Name:RUKEVWE
Middle Name:THEODORA
Last Name:AGHO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 BABCOCK RD APT 1237
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0026
Mailing Address - Country:US
Mailing Address - Phone:210-847-5716
Mailing Address - Fax:
Practice Address - Street 1:2833 BABCOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5390
Practice Address - Country:US
Practice Address - Phone:210-450-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141530363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410153702OtherCSHCN
TX410153701Medicaid