=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265190722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. GILBERT NYAKUNDI OGAMBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2021
-----------------------------------------------------
Last Update Date | 12/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8357 116TH WAY N
-----------------------------------------------------
City | CHAMPLIN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55316-2725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-228-1472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9699 KNIGHTSBRIDGE RD APT 26
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55347-4317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-228-1472
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0400X
-----------------------------------------------------
Taxonomy Name | Case Management Registered Nurse
-----------------------------------------------------
License Number | 2064714
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------