Provider Demographics
NPI:1790289486
Name:EDEMENANG, UBONG- ABASI JAMES
Entity Type:Individual
Prefix:MR
First Name:UBONG- ABASI
Middle Name:JAMES
Last Name:EDEMENANG
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 1:4460 SOUTH HIGHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3503
Mailing Address - Country:US
Mailing Address - Phone:801-263-7101
Mailing Address - Fax:
Practice Address - Street 1:4460 SOUTH HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84124-3503
Practice Address - Country:US
Practice Address - Phone:801-263-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator