Organization
PROVIDENCE NEUROLOGY CLINIC PA
Active
Organization
PROVIDENCE NEUROLOGY CLINIC PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GRACE MUKAMANA MD (MD/OWNER)
(956) 717-4074
Entity
Organization
Contact information
Practice address
220 W HILLSIDE RD, SUITE 5 B, LAREDO, TX 78041-6903
(956) 717-4074
(956) 717-4186
Mailing address
220 W HILLSIDE RD, SUITE 5 B, LAREDO, TX 78041-6903
(956) 717-4074
(956) 717-4186
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
N3913
TX
2084N0600X
Clinical Neurophysiology Physician
N3913
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
210191701
—
TX
Enumeration date
10/07/2009
Last updated
06/21/2012
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