Healthcare Provider Details

I. General information

NPI: 1871159855
Provider Name (Legal Business Name): CHUKWUKA OSCAR NNOLI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 DEMERS AVE
EAST GRAND FORKS MN
56721-1833
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201-4183
US

V. Phone/Fax

Practice location:
  • Phone: 701-795-2000
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0787
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13085
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: