Provider Demographics
NPI:1295066694
Name:OMOKURU, KEYAMO M (DNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KEYAMO
Middle Name:M
Last Name:OMOKURU
Suffix:
Gender:M
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 PARK TEN BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-4293
Mailing Address - Country:US
Mailing Address - Phone:210-261-1000
Mailing Address - Fax:
Practice Address - Street 1:928 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-4444
Practice Address - Country:US
Practice Address - Phone:210-261-1250
Practice Address - Fax:210-434-0716
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 19805164W00000X
TXAP141260363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse