Provider Demographics
NPI:1205612678
Name:MEKOBA, BENNETH IFEYANYI (APN)
Entity type:Individual
Prefix:MR
First Name:BENNETH
Middle Name:IFEYANYI
Last Name:MEKOBA
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203
Mailing Address - Country:US
Mailing Address - Phone:973-495-7914
Mailing Address - Fax:
Practice Address - Street 1:1203 W ST GEORGE AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036
Practice Address - Country:US
Practice Address - Phone:908-583-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14895300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty