Provider Demographics
NPI:1609242916
Name:OGBUAGU, ROYSTON
Entity Type:Individual
Prefix:
First Name:ROYSTON
Middle Name:
Last Name:OGBUAGU
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 1:1600 CENTRAL AVE
Mailing Address - Street 2:VNSNY SUITE
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4000
Mailing Address - Country:US
Mailing Address - Phone:917-416-7490
Mailing Address - Fax:
Practice Address - Street 1:1600 CENTRAL AVE
Practice Address - Street 2:VNSNY SUITE
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4000
Practice Address - Country:US
Practice Address - Phone:917-416-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY627489-1163WP0808X
NY8718453363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health