Provider Demographics
NPI:1578298907
Name:OSEBOR, SAMSON EBHO (RN)
Entity Type:Individual
Prefix:MR
First Name:SAMSON
Middle Name:EBHO
Last Name:OSEBOR
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:667 MAIN ST APT 29
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-2377
Mailing Address - Country:US
Mailing Address - Phone:781-249-8007
Mailing Address - Fax:
Practice Address - Street 1:240 BEAR HILL RD STE 104
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1026
Practice Address - Country:US
Practice Address - Phone:617-340-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311226163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS92075712OtherDRIVER LICENSE