Basic Information
| Provider Information | |||||||||
| NPI: | 1992782007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAHAMA | ||||||||
| FirstName: | NURUDEEN | ||||||||
| MiddleName: | DINTIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2400 S AVENUE A | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853647170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283363213 | ||||||||
| FaxNumber: | 9283363215 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 S AVENUE A | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853647127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283363213 | ||||||||
| FaxNumber: | 9283363215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/19/2006 | ||||||||
| NPIReactivationDate: | 04/13/2007 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0600X | RN281904 | OH | N | Nursing Service Providers | Registered Nurse | Gerontology | 363LA2200X | NP07335 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | AP5554 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | MM3215933 | 01 | DEA | OTHER | MM4624246 | 01 | DEA | OTHER | 2407292 | 05 | OH | MEDICAID |