Basic Information
| Provider Information | |||||||||
| NPI: | 1417107038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUKWUELUE | ||||||||
| FirstName: | N. | ||||||||
| MiddleName: | NELSON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 E. MANSFIELD LANE | ||||||||
| Address2: | 1103 | ||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760633665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176685698 | ||||||||
| FaxNumber: | 8174732298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 W ROSEDALE ST STE 302 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178857888 | ||||||||
| FaxNumber: | 8178857811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
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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 | 363A00000X | PA05934 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 201335101 | 05 | TX | MEDICAID | 201335102 | 05 | TX | MEDICAID | 201335103 | 05 | TX | MEDICAID |