Provider Demographics
NPI:1992380349
Name:OTUADA, MAYOWA MARY
Entity Type:Individual
Prefix:
First Name:MAYOWA
Middle Name:MARY
Last Name:OTUADA
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 1:400 ROSALIND REDFERN GROVER PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5846
Mailing Address - Country:US
Mailing Address - Phone:432-681-3100
Mailing Address - Fax:
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:432-681-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114753363LW0102X
AL1174310163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty