Healthcare Provider Details

I. General information

NPI: 1619509809
Provider Name (Legal Business Name): OMOROGBE NORENSE IGBINEWEKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-7396
  • Fax:
Mailing address:
  • Phone: 510-860-6726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0100X
TaxonomyGastroenterology Registered Nurse
License Number824217
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: