Provider Demographics
NPI:1639695091
Name:OVIASOGIE, MARTIN OSEMWENGIE
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:OSEMWENGIE
Last Name:OVIASOGIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2302
Mailing Address - Country:US
Mailing Address - Phone:315-551-1602
Mailing Address - Fax:
Practice Address - Street 1:329 N SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1755
Practice Address - Country:US
Practice Address - Phone:315-471-1564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY699520163W00000X
NY402562363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse