Healthcare Provider Details

I. General information

NPI: 1003209396
Provider Name (Legal Business Name): OBIOMA GODSWILL ATUFUNWA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2015
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 E POST RD
WHITE PLAINS NY
10601-4607
US

IV. Provider business mailing address

66 W GILBERT ST STE 100
TINTON FALLS NJ
07701-4948
US

V. Phone/Fax

Practice location:
  • Phone: 914-681-0600
  • Fax:
Mailing address:
  • Phone: 732-212-0060
  • Fax: 732-212-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020499
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA057503
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: