Provider Demographics
NPI:1477110443
Name:AWONIYI, OMOBOLAJI ALLYSON (NP)
Entity Type:Individual
Prefix:MS
First Name:OMOBOLAJI
Middle Name:ALLYSON
Last Name:AWONIYI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:OMOBOLAJI
Other - Middle Name:AMINAT
Other - Last Name:OBIDELE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 208354
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8354
Mailing Address - Country:US
Mailing Address - Phone:512-485-7208
Mailing Address - Fax:844-364-8678
Practice Address - Street 1:4100 DUVAL RD STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3550
Practice Address - Country:US
Practice Address - Phone:855-876-7246
Practice Address - Fax:855-277-5070
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011572363LF0000X
TX1019549363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1M9194OtherTEXAS MEDICARE PTAN
TX1M9195OtherTEXAS MEDICARE PTAN
TX1019549OtherTEXAS NP LICENSE
TX1M9200OtherTEXAS MEDICARE PTAN