Provider Demographics
NPI:1649026998
Name:BALOGUN, OLUSHOLA A (NP)
Entity type:Individual
Prefix:
First Name:OLUSHOLA
Middle Name:A
Last Name:BALOGUN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1645
Mailing Address - Country:US
Mailing Address - Phone:214-662-2675
Mailing Address - Fax:
Practice Address - Street 1:811 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1645
Practice Address - Country:US
Practice Address - Phone:214-662-2675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-27
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000117363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health