Provider Demographics
NPI:1194455741
Name:IZEKOR, ABIOLA OYENWEN
Entity Type:Individual
Prefix:
First Name:ABIOLA
Middle Name:OYENWEN
Last Name:IZEKOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5524 BEE CAVES RD STE K4
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5247
Mailing Address - Country:US
Mailing Address - Phone:512-710-0551
Mailing Address - Fax:512-717-6337
Practice Address - Street 1:555 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-0920
Practice Address - Country:US
Practice Address - Phone:940-882-1836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2023-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1083942363LP0808X
CA95023778363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451119803Medicaid