Provider Demographics
NPI:1851785828
Name:EZENWATA, CHINOMSO D (NP-C)
Entity Type:Individual
Prefix:DR
First Name:CHINOMSO
Middle Name:D
Last Name:EZENWATA
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30771
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-0771
Mailing Address - Country:US
Mailing Address - Phone:702-159-7604
Mailing Address - Fax:702-478-6211
Practice Address - Street 1:3110 S DURANGO DR STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117
Practice Address - Country:US
Practice Address - Phone:702-415-9760
Practice Address - Fax:702-478-6211
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1851785828Medicaid
NV1851785828Medicaid
NVPENDINGMedicare PIN