1376812818 NPI number — ISIDORE OBINNA NWAGWU APRN

Table of content: ISIDORE OBINNA NWAGWU APRN (NPI 1376812818)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376812818 NPI number — ISIDORE OBINNA NWAGWU APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NWAGWU
Provider First Name:
ISIDORE
Provider Middle Name:
OBINNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376812818
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 E CENTENNIAL DR
Provider Second Line Business Mailing Address:
# 3&4
Provider Business Mailing Address City Name:
PITTSBURG
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66762-6571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-231-9873
Provider Business Mailing Address Fax Number:
620-231-5062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 E CENTENNIAL DR
Provider Second Line Business Practice Location Address:
# 3&4
Provider Business Practice Location Address City Name:
PITTSBURG
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66762-6571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-231-9873
Provider Business Practice Location Address Fax Number:
620-231-5062
Provider Enumeration Date:
12/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  2011039961 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 53-75487-021 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201071080A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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