Provider Demographics
NPI:1225363906
Name:OMORAGBON, OWEN O (NP)
Entity Type:Individual
Prefix:
First Name:OWEN
Middle Name:O
Last Name:OMORAGBON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 RIVER BEND DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4916
Mailing Address - Country:US
Mailing Address - Phone:972-559-8003
Mailing Address - Fax:
Practice Address - Street 1:1230 RIVER BEND DR STE 105
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4916
Practice Address - Country:US
Practice Address - Phone:972-559-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010877251E00000X
TXAP127005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010877OtherHOME CARE LICENSE