Provider Demographics
NPI:1245853985
Name:OGUGUO, EVARIST O (PMHNP)
Entity type:Individual
Prefix:
First Name:EVARIST
Middle Name:O
Last Name:OGUGUO
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 SOMERTON CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2979
Mailing Address - Country:US
Mailing Address - Phone:240-552-0264
Mailing Address - Fax:
Practice Address - Street 1:110 PAINTERS MILL RD STE 108
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5545
Practice Address - Country:US
Practice Address - Phone:240-552-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR172214363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health