Provider Demographics
NPI:1730936220
Name:GWAN, MAONEKEEKEPOBA
Entity type:Individual
Prefix:
First Name:MAONEKEEKEPOBA
Middle Name:
Last Name:GWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ONEKE
Other - Middle Name:
Other - Last Name:GWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1431 MCHENRY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1431 MCHENRY RD STE 105
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1378
Practice Address - Country:US
Practice Address - Phone:708-892-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist