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NPI Code Detail

MEDICARE: DR. IKE IKPONMWOSA IYAMU DNP, CRNA

MEDICARE: DR. IKE IKPONMWOSA IYAMU DNP, CRNA
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
1367500000XCertified Registered Nurse Anesthetist118612NM

General Provider Information

NPI Number : 1740767482
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. IKE IKPONMWOSA IYAMU DNP, CRNA
Provider Business Mailing Address
First Line : 2471 CONCHAS LN
Second Line :
City : LAS CRUCES
State : NM
Zip : 88011-1733
Country : US
Telephone Number : 713-591-2433
Fax Number :
Provider Business Practice Location Address
First Line : 2450 S TELSHOR BLVD
Second Line :
City : LAS CRUCES
State : NM
Zip : 88011-5076
Country : US
Telephone Number : 575-532-4432
Fax Number : 575-532-4431
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2018
Last Update Date : 07/25/2018

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