Healthcare Provider Details

I. General information

NPI: 1821528951
Provider Name (Legal Business Name): JOSEPH NWABUEZE EZEKWEM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 DUMONT AVE
STATEN ISLAND NY
10305-1450
US

IV. Provider business mailing address

716 FIELD AVE # F9
PLAINFIELD NJ
07060-2355
US

V. Phone/Fax

Practice location:
  • Phone: 908-636-3113
  • Fax:
Mailing address:
  • Phone: 908-636-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number726698-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: