Provider Demographics
NPI:1912686338
Name:WILSON, OMOTEZI (APN)
Entity Type:Individual
Prefix:
First Name:OMOTEZI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 LAUREL OAK RD STE 130
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4419
Mailing Address - Country:US
Mailing Address - Phone:856-857-6920
Mailing Address - Fax:
Practice Address - Street 1:443 LAUREL OAK RD STE 130
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4419
Practice Address - Country:US
Practice Address - Phone:856-857-6920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ148485002084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry