Healthcare Provider Details

I. General information

NPI: 1629713532
Provider Name (Legal Business Name): EMMANUEL NDUBUISI UWALAKA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2213 CHERRY ST
TOLEDO OH
43608-2603
US

IV. Provider business mailing address

1207 CORRAL LN
SOUTH LYON MI
48178-5304
US

V. Phone/Fax

Practice location:
  • Phone: 248-259-1082
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.485413
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.4704271630
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA.239103449
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA.0020694
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: