Provider Demographics
NPI:1376559039
Name:AIGBE, PHILOMENA ODEGUA (NP)
Entity type:Individual
Prefix:
First Name:PHILOMENA
Middle Name:ODEGUA
Last Name:AIGBE
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 1:7805 DOE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2016
Mailing Address - Country:US
Mailing Address - Phone:757-270-3846
Mailing Address - Fax:410-655-2590
Practice Address - Street 1:1001 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2516
Practice Address - Country:US
Practice Address - Phone:757-270-3846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165965363L00000X
MDR185003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010060893Medicaid
VA004632P55Medicare ID - Type Unspecified
VA010060893Medicaid