Provider Demographics
NPI:1144560293
Name:NYAMBEGERA, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:NYAMBEGERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12724 NE 38TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:OK
Mailing Address - Zip Code:73084-9155
Mailing Address - Country:US
Mailing Address - Phone:505-553-8292
Mailing Address - Fax:
Practice Address - Street 1:7250 NW EXPRESSWAY
Practice Address - Street 2:STE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-1534
Practice Address - Country:US
Practice Address - Phone:405-525-0452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100719930AMedicaid