Provider Demographics
NPI:1528540952
Name:UMAH-MGBOROGWU, DANIEL TOCHUKWU (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:TOCHUKWU
Last Name:UMAH-MGBOROGWU
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PEPPER AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:619-549-2178
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE STE 107
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:619-549-2178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-01
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant