Healthcare Provider Details

I. General information

NPI: 1437660586
Provider Name (Legal Business Name): IGNATIUS NJI MBUA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 WESTERN BLVD
RALEIGH NC
27606-2148
US

IV. Provider business mailing address

103 PINEGATE CIR APT 10
CHAPEL HILL NC
27514-2248
US

V. Phone/Fax

Practice location:
  • Phone: 919-743-2232
  • Fax:
Mailing address:
  • Phone: 708-890-3309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5009608
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: