Provider Demographics
NPI:1700929841
Name:OKONKWO, HENRY
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:OKONKWO
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 1:11041 SANTA MONICA BLVD # 515
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3523
Mailing Address - Country:US
Mailing Address - Phone:310-464-7042
Mailing Address - Fax:888-400-4948
Practice Address - Street 1:976 BLACKBERRY LN
Practice Address - Street 2:
Practice Address - City:DOMINGUEZ HILLS
Practice Address - State:CA
Practice Address - Zip Code:90746
Practice Address - Country:US
Practice Address - Phone:310-464-7042
Practice Address - Fax:310-756-6500
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA16806FMedicare PIN
CAWPA16806DMedicare PIN
CAWPA16806GMedicare PIN
CAWPA16806EMedicare PIN