Healthcare Provider Details

I. General information

NPI: 1093587412
Provider Name (Legal Business Name): UTOMOBONG ISOK GNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9903 DEHAVILLAND WAY APT J
MIDDLE RIVER MD
21220-2674
US

IV. Provider business mailing address

9903 DEHAVILLAND WAY APT J
MIDDLE RIVER MD
21220-2674
US

V. Phone/Fax

Practice location:
  • Phone: 786-781-5855
  • Fax:
Mailing address:
  • Phone: 786-781-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00200014
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: