Healthcare Provider Details

I. General information

NPI: 1881488872
Provider Name (Legal Business Name): EJIROGHENE IDOLOR MSN, AGPCNP-BC
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 GRANT AVE APT 3
BRONX NY
10456-3191
US

IV. Provider business mailing address

1250 GRANT AVE APT 3
BRONX NY
10456-3191
US

V. Phone/Fax

Practice location:
  • Phone: 803-290-6363
  • Fax:
Mailing address:
  • Phone: 803-290-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: