Healthcare Provider Details

I. General information

NPI: 1447717665
Provider Name (Legal Business Name): MICHAEL NGETICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2019
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 S UNION ST
PETERSBURG VA
23803-4221
US

IV. Provider business mailing address

25 S UNION ST
PETERSBURG VA
23803-4221
US

V. Phone/Fax

Practice location:
  • Phone: 804-957-9601
  • Fax:
Mailing address:
  • Phone: 804-957-9601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018039615
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: