Provider Demographics
NPI:1427576701
Name:OMIGIE, GODWN EMOBEFO
Entity Type:Individual
Prefix:
First Name:GODWN
Middle Name:EMOBEFO
Last Name:OMIGIE
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 1:203 MENTOR DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-5435
Mailing Address - Country:US
Mailing Address - Phone:817-262-3254
Mailing Address - Fax:
Practice Address - Street 1:2261 BROOKHOLLOW PLAZA DR STE 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-7417
Practice Address - Country:US
Practice Address - Phone:832-967-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner