Healthcare Provider Details

I. General information

NPI: 1912797077
Provider Name (Legal Business Name): ONYEKA PIUS MBANU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 05/10/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VIRGINIA ST NE APT 32
ALBUQUERQUE NM
87110-7631
US

IV. Provider business mailing address

1400 VIRGINIA ST NE APT 32
ALBUQUERQUE NM
87110-7631
US

V. Phone/Fax

Practice location:
  • Phone: 505-523-5641
  • Fax:
Mailing address:
  • Phone: 505-523-5641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: