Healthcare Provider Details

I. General information

NPI: 1104835966
Provider Name (Legal Business Name): GODWIN OKUNGBOWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 L ST
SACRAMENTO CA
95816-5248
US

IV. Provider business mailing address

3441 MARYSVILLE BLVD
SACRAMENTO CA
95838-4512
US

V. Phone/Fax

Practice location:
  • Phone: 916-737-7121
  • Fax: 916-737-7135
Mailing address:
  • Phone: 916-563-7230
  • Fax: 916-563-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: