Provider Demographics
NPI:1467992719
Name:SOFOWORA-AUSTIN, OMOBOLANLE MUTIAT (NP)
Entity Type:Individual
Prefix:
First Name:OMOBOLANLE
Middle Name:MUTIAT
Last Name:SOFOWORA-AUSTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 HAYES RD APT 734
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-6637
Mailing Address - Country:US
Mailing Address - Phone:917-202-6310
Mailing Address - Fax:
Practice Address - Street 1:2828 HAYES RD APT 734
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-6637
Practice Address - Country:US
Practice Address - Phone:917-202-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132168363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health