Provider Demographics
NPI:1396252037
Name:IGBOANUGO, IFEANYI EMMANUEL (MPH, MSN, AGNP-C)
Entity type:Individual
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First Name:IFEANYI
Middle Name:EMMANUEL
Last Name:IGBOANUGO
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Gender:M
Credentials:MPH, MSN, AGNP-C
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Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:623-974-6721
Practice Address - Street 1:15351 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4580
Practice Address - Country:US
Practice Address - Phone:480-964-2273
Practice Address - Fax:623-214-5214
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2023-12-22
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Provider Licenses
StateLicense IDTaxonomies
AZAP10856363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ372652Medicaid