Basic Information
| Provider Information | |||||||||
| NPI: | 1154897502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETUOKWU | ||||||||
| FirstName: | EMMANUEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 W TERRELL AVE STE K230 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 W TERRELL AVE STE K230 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172504906 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2018 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 731092 | TX | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP139648 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | AP139648 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | AP139648 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | AP139648 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.