Provider Demographics
NPI:1710080205
Name:ERHUNMWUNSE, GIBSON IYEKE (NP)
Entity Type:Individual
Prefix:MR
First Name:GIBSON
Middle Name:IYEKE
Last Name:ERHUNMWUNSE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 CORNFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603
Mailing Address - Country:US
Mailing Address - Phone:301-885-1587
Mailing Address - Fax:
Practice Address - Street 1:550 S CARLIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204
Practice Address - Country:US
Practice Address - Phone:703-379-7200
Practice Address - Fax:703-578-5524
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017138050363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00260751OtherRR MEDICARE
VA010239796Medicaid
Q52072Medicare UPIN
VA010239796Medicaid