Healthcare Provider Details

I. General information

NPI: 1558041657
Provider Name (Legal Business Name): AMBROSE OWIE OBASOHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 08/02/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 GEARY BLVD FL 2
SAN FRANCISCO CA
94121-1834
US

IV. Provider business mailing address

1220 KENTWOOD LN APT 801
SAN LEANDRO CA
94578-2368
US

V. Phone/Fax

Practice location:
  • Phone: 415-386-6600
  • Fax: 415-751-3226
Mailing address:
  • Phone: 510-904-2934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: