Provider Demographics
NPI:1578132973
Name:THOMAS - AWOYERA, VICTORIA AINA BOLANLE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:AINA BOLANLE
Last Name:THOMAS - AWOYERA
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 1:1434 WILLIAMSBRIDGE RD FL 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2507
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-618-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health