Provider Demographics
NPI:1568560407
Name:OKUNGBOWA, ROLAND OGOMWEN (CRNA)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:OGOMWEN
Last Name:OKUNGBOWA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7145 PERKINS ROAD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4322
Mailing Address - Country:US
Mailing Address - Phone:225-765-3111
Mailing Address - Fax:225-765-3114
Practice Address - Street 1:7145 PERKINS ROAD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4322
Practice Address - Country:US
Practice Address - Phone:225-765-3111
Practice Address - Fax:225-765-3114
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04753367500000X
LARN-096621-AP04753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5M879Medicare ID - Type Unspecified
LAB62069Medicare UPIN