Provider Demographics
NPI:1700247418
Name:OMOTOSO, KIKELOMO
Entity Type:Individual
Prefix:
First Name:KIKELOMO
Middle Name:
Last Name:OMOTOSO
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 1:2500 CANYON RD
Mailing Address - Street 2:STE A1
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442
Mailing Address - Country:US
Mailing Address - Phone:928-704-4499
Mailing Address - Fax:928-704-4949
Practice Address - Street 1:2500 CANYON RD
Practice Address - Street 2:STE A1
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-704-4499
Practice Address - Fax:928-704-4949
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8360363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology