Basic Information
| Provider Information | |||||||||
| NPI: | 1881162527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOGUSU | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MORAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12187 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309142187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 COIT RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750756172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068639595 | ||||||||
| FaxNumber: | 7068688375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2018 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP138452 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.