Provider Demographics
NPI:1154056620
Name:IMOUKHUEDE, IZIEN IRUOBE (MD)
Entity Type:Individual
Prefix:
First Name:IZIEN
Middle Name:IRUOBE
Last Name:IMOUKHUEDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9710 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2232
Mailing Address - Country:US
Mailing Address - Phone:360-653-1742
Mailing Address - Fax:
Practice Address - Street 1:9710 STATE AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2232
Practice Address - Country:US
Practice Address - Phone:360-653-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMDRE.ML.61304643390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program