Provider Demographics
NPI:1962903435
Name:OKONKWO, PIUS OLISADEBE
Entity type:Individual
Prefix:
First Name:PIUS
Middle Name:OLISADEBE
Last Name:OKONKWO
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 1:11851 HIDEOUT TRL
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-1103
Mailing Address - Country:US
Mailing Address - Phone:214-909-1405
Mailing Address - Fax:
Practice Address - Street 1:11851 HIDEOUT TRL
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-1103
Practice Address - Country:US
Practice Address - Phone:214-909-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222587364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22716550OtherDRIVERS LICENSE