Provider Demographics
NPI:1306352638
Name:IDAHOSA, NCHEDOCHUKWU (PA)
Entity type:Individual
Prefix:
First Name:NCHEDOCHUKWU
Middle Name:
Last Name:IDAHOSA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PARK CENTER CT STE 200
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4221
Mailing Address - Country:US
Mailing Address - Phone:443-693-7246
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 18
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2132
Practice Address - Country:US
Practice Address - Phone:443-693-7246
Practice Address - Fax:443-399-8309
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant