MEDICARE: SAMUEL NWANEKPE

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11050	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R 154140-3	OTHER	MN	MINNESOTA BOARD OF NURSING

General Provider Information

NPI Number	:	1861845281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL NWANEKPE

Provider Business Mailing Address
First Line	:	2623 GREY EAGLE DR
Second Line	:
City	:	WOODBURY
State	:	MN
Zip	:	55129-4297
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 UNIVERSITY AVE W STE S348
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-2876
Country	:	US
Telephone Number	:	651-493-3834
Fax Number	:	651-493-3835

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

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	11/21/2023

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