Basic Information
| Provider Information | |||||||||
| NPI: | 1023538576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | UGWU | ||||||||
| FirstName: | BOMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 COLLEGE AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852704630 | ||||||||
| FaxNumber: | 7852704628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLLEGE AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN | ||||||||
| State: | KS | ||||||||
| PostalCode: | 665022770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852704630 | ||||||||
| FaxNumber: | 7852704628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2017 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 04-43615 | KS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1P0610 | 01 | TX | PTAN | OTHER |