Provider Demographics
NPI:1902810393
Name:MADUEKE, PRISCILLIA
Entity Type:Individual
Prefix:
First Name:PRISCILLIA
Middle Name:
Last Name:MADUEKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 REGENT BLVD
Mailing Address - Street 2:#200
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-3196
Mailing Address - Country:US
Mailing Address - Phone:214-689-8079
Mailing Address - Fax:
Practice Address - Street 1:3050 REGENT BLVD
Practice Address - Street 2:#200
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3196
Practice Address - Country:US
Practice Address - Phone:214-689-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130444363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
5805490001Medicare NSC
TX185103202Medicaid
TX185103203Medicaid
TX185103201Medicaid