Provider Demographics
NPI:1891193694
Name:NWOSU, MARCELLINA (NP)
Entity Type:Individual
Prefix:
First Name:MARCELLINA
Middle Name:
Last Name:NWOSU
Suffix:
Gender:F
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:PO BOX 221530
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-4530
Mailing Address - Country:US
Mailing Address - Phone:915-598-7246
Mailing Address - Fax:
Practice Address - Street 1:2730 N WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6519
Practice Address - Country:US
Practice Address - Phone:575-395-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-55239363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28586271Medicaid
NM28586271Medicaid