Provider Demographics
NPI:1801280177
Name:BRAIMAH, OMUWA
Entity type:Individual
Prefix:
First Name:OMUWA
Middle Name:
Last Name:BRAIMAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 GATEWAY CT
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-8539
Mailing Address - Country:US
Mailing Address - Phone:262-335-8600
Mailing Address - Fax:
Practice Address - Street 1:1100 GATEWAY CT
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095
Practice Address - Country:US
Practice Address - Phone:262-335-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67105-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100065610Medicaid