Provider Demographics
NPI:1609321181
Name:OGUNYOMI, FISAYO (FNP)
Entity Type:Individual
Prefix:
First Name:FISAYO
Middle Name:
Last Name:OGUNYOMI
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13727 246TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1838
Mailing Address - Country:US
Mailing Address - Phone:917-880-0579
Mailing Address - Fax:
Practice Address - Street 1:13727 246TH ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1838
Practice Address - Country:US
Practice Address - Phone:917-880-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341006-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily