Provider Demographics
NPI:1659098416
Name:OTUNUGA, ABISOYE M
Entity Type:Individual
Prefix:
First Name:ABISOYE
Middle Name:M
Last Name:OTUNUGA
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 1:12 BAYARD PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3634
Mailing Address - Country:US
Mailing Address - Phone:201-349-6816
Mailing Address - Fax:
Practice Address - Street 1:12 BAYARD PL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3634
Practice Address - Country:US
Practice Address - Phone:201-349-6816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01349400363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health