Provider Demographics
NPI:1316742760
Name:IGBERAESE, FAITH OMAMOGHO
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:OMAMOGHO
Last Name:IGBERAESE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5873 S NEPAL ST
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-3353
Mailing Address - Country:US
Mailing Address - Phone:720-289-5051
Mailing Address - Fax:
Practice Address - Street 1:5873 S NEPAL ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-3353
Practice Address - Country:US
Practice Address - Phone:720-289-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0182083163WM0705X
COAPN.1000499-NP207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine