Basic Information
| Provider Information | |||||||||
| NPI: | 1538717103 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OTAGHO | ||||||||
| FirstName: | ETINOSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21711 130TH AVE | ||||||||
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| City: | SPRINGFIELD GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114131204 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
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| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| ProviderEnumerationDate: | 08/27/2019 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.