Provider Demographics
NPI:1336770312
Name:OLATUNBOSUN, MORAYO (NP)
Entity Type:Individual
Prefix:
First Name:MORAYO
Middle Name:
Last Name:OLATUNBOSUN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BUNCH GRASS TER
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-8409
Mailing Address - Country:US
Mailing Address - Phone:215-667-5632
Mailing Address - Fax:
Practice Address - Street 1:150 MUIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4668
Practice Address - Country:US
Practice Address - Phone:215-667-5632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily