=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508431107
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN OTUNDO NYABERA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2021
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 NASH MEDICAL ARTS MALL STE D
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27804-1470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-451-2700
-----------------------------------------------------
Fax | 252-451-2702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 HOPE VALLEY RD
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-6767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-637-3524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 33001
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 33001
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2024-02979
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------