Healthcare Provider Details

I. General information

NPI: 1174427363
Provider Name (Legal Business Name): DAMIETE PATRICK IPALIBO WOKOMA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W 129TH ST
NEW YORK NY
10027-2292
US

IV. Provider business mailing address

60 W 129TH ST APT 406
NEW YORK NY
10027-2295
US

V. Phone/Fax

Practice location:
  • Phone: 646-956-9475
  • Fax:
Mailing address:
  • Phone: 646-956-9475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF360939
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: