Healthcare Provider Details

I. General information

NPI: 1376812818
Provider Name (Legal Business Name): ISIDORE OBINNA NWAGWU APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E CENTENNIAL DR # 3&4
PITTSBURG KS
66762-6571
US

IV. Provider business mailing address

200 E CENTENNIAL DR # 3&4
PITTSBURG KS
66762-6571
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-5062
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2011039961
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-75487-021
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: