Provider Demographics
NPI:1659995595
Name:OKORONKWO, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:OKORONKWO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7655 W MARY JANE LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3842
Mailing Address - Country:US
Mailing Address - Phone:602-348-1338
Mailing Address - Fax:602-297-6566
Practice Address - Street 1:7075 W BELL RD STE A-1
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8546
Practice Address - Country:US
Practice Address - Phone:602-348-1338
Practice Address - Fax:602-297-6566
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-06
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ241990363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health