MEDICARE: MR. BETHRAND OKAFOR UGWU PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	13543	GA

General Provider Information

NPI Number	:	1437021649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BETHRAND OKAFOR UGWU PA-C

Provider Business Mailing Address
First Line	:	1030 BERMUDA RUN
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-0858
Country	:	US
Telephone Number	:	912-764-8396
Fax Number	:	912-764-7188

Provider Business Practice Location Address
First Line	:	1030 BERMUDA RUN
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-0858
Country	:	US
Telephone Number	:	912-764-8396
Fax Number	:	912-764-7188

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2025
Last Update Date	:	12/17/2025

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