Provider Demographics
NPI:1659930899
Name:OBETA, INNOCENT
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:OBETA
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 1:5411 GEMSTONE PARK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-4161
Mailing Address - Country:US
Mailing Address - Phone:832-533-6047
Mailing Address - Fax:
Practice Address - Street 1:5411 GEMSTONE PARK RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-4161
Practice Address - Country:US
Practice Address - Phone:832-533-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX787427163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse