Provider Demographics
NPI:1275107914
Name:ONAGORUWA, ADEDIRAN TOBI
Entity Type:Individual
Prefix:
First Name:ADEDIRAN
Middle Name:TOBI
Last Name:ONAGORUWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 CHARING CROSS WAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-2880
Mailing Address - Country:US
Mailing Address - Phone:336-382-9766
Mailing Address - Fax:
Practice Address - Street 1:1421 CHARING CROSS WAY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-2880
Practice Address - Country:US
Practice Address - Phone:336-382-9766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC244450163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health