IRENE ENJEMA EKOBENA, NP — NPI 1255115473 (Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Gerontology in EXCELSIOR, MN)

CMS-1500 Box 24J / 33a • NPI

1255115473

Type 1 Individual Rendering/Ordering

HIPAA NUCC Taxonomy • CMS Code

363LG0600X (CMS 50)

Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Gerontology

Box 32 Service Location & ZIP+4

464 2ND ST STE 204, EXCELSIOR, MN, 55331-2015

✓ 9-Digit EDI 837 ZIP+4 (55331-2015)

Practice Phone & Referral Fax

(612) 787-8408

Fax: (612) 567-8935

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1255115473 (IRENE ENJEMA EKOBENA, NP) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

This practitioner does not currently appear in the CMS individual Order & Referring PECOS file (may practice in pediatrics, commercial-only networks, or hospital-employed settings).

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1255115473` (NPI-1 Individual Practitioner)
Provider / Legal Name	IRENE ENJEMA EKOBENA, NP
Plain-English Specialty	Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Gerontology NUCC Code: `363LG0600X` (Nurse Practitioner, Gerontology)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	464 2ND ST STE 204, EXCELSIOR, MN, 55331-2015
Practice Telephone / Fax	Tel: (612) 787-8408 \| Fax: (612) 567-8935
Administrative Mailing Address	464 2ND ST STE 204, EXCELSIOR, MN, 55331-2015
Enumeration & Last Sync	Enumerated: 2023-08-21 \| CMS Record Updated: 2025-02-20

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

464 2ND ST STE 204, EXCELSIOR, MN, 55331-2015

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Plain-English Taxonomy & CMS Crosswalk (363LG0600X)

What Does Taxonomy Code 363LG0600X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363LG0600X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Gerontology"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 50 (Nurse Practitioner)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Nurse Practitioner, Gerontology for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (IRENE ENJEMA EKOBENA, NP)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`363LG0600X` — Nurse Practitioner, Gerontology Plain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Gerontology	State: MN \| License: `10642` \| Primary: Yes (Primary)

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IRENE ENJEMA EKOBENA, NP (NPI #1255115473)