Provider Demographics
NPI:1568428431
Name:DWOMOH, NANA N (DO)
Entity Type:Individual
Prefix:DR
First Name:NANA
Middle Name:N
Last Name:DWOMOH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40850
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85274
Mailing Address - Country:US
Mailing Address - Phone:480-839-3313
Mailing Address - Fax:480-839-4182
Practice Address - Street 1:1201 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007
Practice Address - Country:US
Practice Address - Phone:602-258-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4290207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3981220OtherEVERCARE GRP
AZ969206Medicaid
AZAZ0728670OtherBLUE CROSS BLUE SHIELD GR
AZ453051001OtherGROUP HEALTH GRP
AZAW1436OtherHEALTHNET GRP
AZ860373636OtherHUMANA GROUP
I43807Medicare UPIN
AZ3981220OtherEVERCARE GRP