Provider Demographics
NPI:1104835966
Name:OKUNGBOWA, GODWIN
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:
Last Name:OKUNGBOWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 MARYSVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-4512
Mailing Address - Country:US
Mailing Address - Phone:916-563-7230
Mailing Address - Fax:916-563-7229
Practice Address - Street 1:3000 L ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5248
Practice Address - Country:US
Practice Address - Phone:916-737-7121
Practice Address - Fax:916-737-7135
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical