Provider Demographics
NPI:1912263831
Name:IGBIDE, PAUL O (ANP-BC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:O
Last Name:IGBIDE
Suffix:
Gender:M
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 HEMPSTEAD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2050
Mailing Address - Country:US
Mailing Address - Phone:516-500-9905
Mailing Address - Fax:855-844-6939
Practice Address - Street 1:354 HEMPSTEAD AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2050
Practice Address - Country:US
Practice Address - Phone:516-500-9905
Practice Address - Fax:855-844-6939
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305988363LA2200X
NY404221363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04785897Medicaid