Provider Demographics
NPI:1922251891
Name:MPAMA, BENSON IROAMACHI
Entity Type:Individual
Prefix:
First Name:BENSON
Middle Name:IROAMACHI
Last Name:MPAMA
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 1:232 18 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413
Mailing Address - Country:US
Mailing Address - Phone:718-528-3432
Mailing Address - Fax:
Practice Address - Street 1:232 18 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413
Practice Address - Country:US
Practice Address - Phone:718-528-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229153164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010556898Medicaid