Provider Demographics
NPI:1912668500
Name:ODISHO, JWAN (AGACNP)
Entity Type:Individual
Prefix:
First Name:JWAN
Middle Name:
Last Name:ODISHO
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 W GERMANN RD APT 1159
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-7270
Mailing Address - Country:US
Mailing Address - Phone:847-714-7116
Mailing Address - Fax:
Practice Address - Street 1:1900 N HIGLEY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1604
Practice Address - Country:US
Practice Address - Phone:480-543-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN208331163WX0200X
AZ269456363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No163WX0200XNursing Service ProvidersRegistered NurseOncologyGroup - Single Specialty