Healthcare Provider Details

I. General information

NPI: 1497084131
Provider Name (Legal Business Name): ELERA YEYE NWOGU P.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7940 JOHNSON AVE
GLENARDEN MD
20706-1772
US

IV. Provider business mailing address

2512 NICOL CIR
MITCHELLVILLE MD
20721-2955
US

V. Phone/Fax

Practice location:
  • Phone: 301-341-5450
  • Fax: 301-341-2424
Mailing address:
  • Phone: 301-925-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002905
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA030294
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: