Provider Demographics
NPI:1124594668
Name:OMOLE, OMOTAYO ABIODUN (PT)
Entity Type:Individual
Prefix:MISS
First Name:OMOTAYO
Middle Name:ABIODUN
Last Name:OMOLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2575 W 24TH ST APT 254
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6069
Mailing Address - Country:US
Mailing Address - Phone:928-723-6744
Mailing Address - Fax:
Practice Address - Street 1:2575 W 24TH ST APT 254
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-6069
Practice Address - Country:US
Practice Address - Phone:928-723-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1274336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist