Provider Demographics
NPI:1376024315
Name:OBINERO, EMMANUEL IKENNA (PTA)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:IKENNA
Last Name:OBINERO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 ROMA DRIVE
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:631-987-4936
Mailing Address - Fax:
Practice Address - Street 1:1185 ROMA DRIVE
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7503
Practice Address - Country:US
Practice Address - Phone:631-987-4936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2108530225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant