Healthcare Provider Details

I. General information

NPI: 1952159253
Provider Name (Legal Business Name): MATILDA OTANG EYONG EPSE EBAIETAKA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 S ROME STREET
GILBERT AZ
85297
US

IV. Provider business mailing address

6945 S OPAL DR
CHANDLER AZ
85249-7221
US

V. Phone/Fax

Practice location:
  • Phone: 480-677-5500
  • Fax:
Mailing address:
  • Phone: 480-452-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number223835
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: