Healthcare Provider Details

I. General information

NPI: 1750649455
Provider Name (Legal Business Name): IKENNA E OBASI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 WEIR DR STE 270
WOODBURY MN
55125-6741
US

IV. Provider business mailing address

1100 LAKE VIEW DR
WAUSAU WI
54403-6785
US

V. Phone/Fax

Practice location:
  • Phone: 651-714-9646
  • Fax: 651-714-9647
Mailing address:
  • Phone: 715-848-4454
  • Fax: 715-845-5398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number56761
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number56761
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number63230
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: