Provider Demographics
NPI:1033800503
Name:OMOTOSHO, OLAYEMI (NP)
Entity Type:Individual
Prefix:
First Name:OLAYEMI
Middle Name:
Last Name:OMOTOSHO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2318 SWEETWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2970
Mailing Address - Country:US
Mailing Address - Phone:832-495-2908
Mailing Address - Fax:
Practice Address - Street 1:408 S DALLAS ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5320
Practice Address - Country:US
Practice Address - Phone:832-495-2908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1119120363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health