Healthcare Provider Details

I. General information

NPI: 1619631215
Provider Name (Legal Business Name): OBIRI YEBOAH APRN AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 09/15/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

PO BOX 6633
BROOKINGS OR
97415-0288
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2081
Mailing address:
  • Phone: 707-954-6068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number202110590NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: