Provider Demographics
NPI:1871166421
Name:GWAYA, SAMUEL NYAWANSA
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:NYAWANSA
Last Name:GWAYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 LAKE HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-2055
Mailing Address - Country:US
Mailing Address - Phone:682-554-3270
Mailing Address - Fax:
Practice Address - Street 1:2224 LAKE HAVEN LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-2055
Practice Address - Country:US
Practice Address - Phone:682-554-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1048011363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health