Healthcare Provider Details

I. General information

NPI: 1700929841
Provider Name (Legal Business Name): HENRY OKONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 BLACKBERRY LN
DOMINGUEZ HILLS CA
90746
US

IV. Provider business mailing address

11041 SANTA MONICA BLVD # 515
LOS ANGELES CA
90025-3523
US

V. Phone/Fax

Practice location:
  • Phone: 310-464-7042
  • Fax: 310-756-6500
Mailing address:
  • Phone: 310-464-7042
  • Fax: 888-400-4948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16806
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: