MEDICARE: NWOGO NNUNWA AGBASI MD

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	207V00000X	Obstetrics & Gynecology Physician	MD420965	PA
2	207V00000X	Obstetrics & Gynecology Physician	25MA08155300	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740279744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NWOGO NNUNWA AGBASI MD

Provider Business Mailing Address
First Line	:	PO BOX 22581
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10087-2581
Country	:	US
Telephone Number	:	609-878-8003
Fax Number	:

Provider Business Practice Location Address
First Line	:	6601 VENTNOR AVE STE 14
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-2172
Country	:	US
Telephone Number	:	609-878-8003
Fax Number	:

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	03/19/2021

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