1821310426 NPI number — AMITHA BENA OMONUWA PA-C

Table of content: AMITHA BENA OMONUWA PA-C (NPI 1821310426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821310426 NPI number — AMITHA BENA OMONUWA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OMONUWA
Provider First Name:
AMITHA
Provider Middle Name:
BENA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1821310426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33902-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-343-9960
Provider Business Mailing Address Fax Number:
239-424-4006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 DEL PRADO BLVD S STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33990-2676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-343-9960
Provider Business Practice Location Address Fax Number:
239-424-4006
Provider Enumeration Date:
02/23/2010

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: 363A00000X , with the licence number:  PA9109689 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 354613564A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 019421700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 354613564B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 551847 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 01348305 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 019421700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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