Basic Information
| Provider Information | |||||||||
| NPI: | 1124423124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGU | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | CHIOMA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4439 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137922991 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1515 HOLCOMBE BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137926161 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2014 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 719144 | TX | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP126056 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 343114002 (MDACC) | 05 | TX | MEDICAID | 0035TD | 01 | TX | BCBSTX GRP PROV RECORD # | OTHER | 153449704 | 01 | TX | MDCD GRP TPI # | OTHER | 387035YNBT | 01 | TX | INDIV MDCR PTAN | OTHER | 00106W | 01 | TX | MDCR GRP PTAN # | OTHER |