Provider Demographics
NPI:1356879878
Name:GARUBA, IZIEGBE (NP)
Entity type:Individual
Prefix:
First Name:IZIEGBE
Middle Name:
Last Name:GARUBA
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 1:83 BIRCHFIELD CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0844
Mailing Address - Country:US
Mailing Address - Phone:334-354-3388
Mailing Address - Fax:
Practice Address - Street 1:1800 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2705
Practice Address - Country:US
Practice Address - Phone:209-572-7262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-29
Last Update Date:2017-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221346363L00000X
CA95006660363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner