Healthcare Provider Details

I. General information

NPI: 1063831824
Provider Name (Legal Business Name): BETHEL UBOCHI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 SYCAMORE DR APT 58
GREEN BAY WI
54311-5166
US

IV. Provider business mailing address

121 WOODROSE CT
ROSEBURG OR
97471-1646
US

V. Phone/Fax

Practice location:
  • Phone: 920-931-5061
  • Fax:
Mailing address:
  • Phone: 920-931-5061
  • Fax: 541-440-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number173722-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number113028-23
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202001123
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: