Basic Information
| Provider Information | |||||||||
| NPI: | 1457755787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESSIEN | ||||||||
| FirstName: | EKOMOBONG | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 808 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465287100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745340088 | ||||||||
| FaxNumber: | 5749718434 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 S US HIGHWAY 131 | ||||||||
| Address2: | |||||||||
| City: | THREE RIVERS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490938831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692867070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2014 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 19247 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 71005470B | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 4704395587 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q008780 | 05 | TN | MEDICAID |