Provider Demographics
NPI:1154676021
Name:OMOSOWON, SAMSON FOLORUNSHO (RN, CSCM)
Entity Type:Individual
Prefix:MR
First Name:SAMSON
Middle Name:FOLORUNSHO
Last Name:OMOSOWON
Suffix:
Gender:M
Credentials:RN, CSCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4078 E ASPEN WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-7506
Mailing Address - Country:US
Mailing Address - Phone:480-335-3099
Mailing Address - Fax:480-621-8748
Practice Address - Street 1:4078 E ASPEN WAY
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-7506
Practice Address - Country:US
Practice Address - Phone:480-335-3099
Practice Address - Fax:480-621-8748
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN156392251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ658864Medicaid
AZRN156392Medicaid