Healthcare Provider Details

I. General information

NPI: 1003666728
Provider Name (Legal Business Name): JOHN-PAUL OBAE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 E PHILLIPS BLVD UNIT 10
POMONA CA
91766-7553
US

IV. Provider business mailing address

961 E PHILLIPS BLVD UNIT 10
POMONA CA
91766-7553
US

V. Phone/Fax

Practice location:
  • Phone: 816-694-2924
  • Fax:
Mailing address:
  • Phone: 816-694-2924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95184987
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: