Provider Demographics
NPI:1285472563
Name:MEKOBA, BIANCA EZENWANYI (NP)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:EZENWANYI
Last Name:MEKOBA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-4309
Mailing Address - Country:US
Mailing Address - Phone:973-483-1300
Mailing Address - Fax:
Practice Address - Street 1:741 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4309
Practice Address - Country:US
Practice Address - Phone:973-483-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF421754-01363LW0102X
NJ26NJ15082600363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health