Provider Demographics
NPI:1023836954
Name:ONWUKWE, MAHADO ISMAIL
Entity type:Individual
Prefix:
First Name:MAHADO
Middle Name:ISMAIL
Last Name:ONWUKWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 E LAKE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2485
Mailing Address - Country:US
Mailing Address - Phone:320-980-6031
Mailing Address - Fax:
Practice Address - Street 1:334 E LAKE ST STE 104
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2485
Practice Address - Country:US
Practice Address - Phone:320-980-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker