Healthcare Provider Details

I. General information

NPI: 1861237679
Provider Name (Legal Business Name): GERALD OBAIGWA OMBASA FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CENTRAL AVE
EAST ORANGE NJ
07018-2819
US

IV. Provider business mailing address

5549 BRIDLE RD
STROUDSBURG PA
18360-9197
US

V. Phone/Fax

Practice location:
  • Phone: 201-892-6071
  • Fax:
Mailing address:
  • Phone: 201-892-6071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP036549
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP029789
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: