1952159253 NPI number — MATILDA OTANG EYONG EPSE EBAIETAKA PMHNP

Table of content: MATILDA OTANG EYONG EPSE EBAIETAKA PMHNP (NPI 1952159253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952159253 NPI number — MATILDA OTANG EYONG EPSE EBAIETAKA PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EYONG EPSE EBAIETAKA
Provider First Name:
MATILDA
Provider Middle Name:
OTANG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
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:
1952159253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6945 S OPAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85249-7221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-452-6424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3755 S ROME STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-677-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2024

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: 363LP0808X , with the licence number:  223835 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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