Provider Demographics
NPI:1083261390
Name:OMOROGBE, SAMUEL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:OMOROGBE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:7908 MODESTO DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-6102
Mailing Address - Country:US
Mailing Address - Phone:817-501-4559
Mailing Address - Fax:
Practice Address - Street 1:7908 MODESTO DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-6102
Practice Address - Country:US
Practice Address - Phone:817-501-4559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142663363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health