Provider Demographics
NPI:1134901499
Name:OMBA, CHISHUGI IZUBA
Entity type:Individual
Prefix:
First Name:CHISHUGI
Middle Name:IZUBA
Last Name:OMBA
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 1:1603 N SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2026
Mailing Address - Country:US
Mailing Address - Phone:316-461-4764
Mailing Address - Fax:
Practice Address - Street 1:1603 N SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-2026
Practice Address - Country:US
Practice Address - Phone:316-461-4764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15433747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty