Provider Demographics
NPI:1114559176
Name:OKEKE, THERESA NKECHINYEREM (PA-C)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:NKECHINYEREM
Last Name:OKEKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5697
Mailing Address - Country:US
Mailing Address - Phone:619-452-5397
Mailing Address - Fax:
Practice Address - Street 1:5931 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5697
Practice Address - Country:US
Practice Address - Phone:619-452-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant