Healthcare Provider Details

I. General information

NPI: 1578990693
Provider Name (Legal Business Name): NTAOBASI PATRICK UDEH AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6158 FAIRBOURNE CT
HANOVER MD
21076-1000
US

IV. Provider business mailing address

6158 FAIRBOURNE CT
HANOVER MD
21076-1000
US

V. Phone/Fax

Practice location:
  • Phone: 240-856-0529
  • Fax:
Mailing address:
  • Phone: 240-856-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR229826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: