MEDICARE: MRS. OLUWANISHOLA BASHORUN M.S. P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3175	AZ
2	225100000X	Physical Therapist	2305205701	VA
3	225100000X	Physical Therapist	1399638	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1399638	OTHER	TX	STATE LICENSE
2	2305205701	OTHER	VA	STATE LICENSURE
3	3175	OTHER	AZ	STATE LICENSE INFORMATION

General Provider Information

NPI Number	:	1184761116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. OLUWANISHOLA BASHORUN M.S. P.T.

Provider Business Mailing Address
First Line	:	5309 WURZBACH RD STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-2431
Country	:	US
Telephone Number	:	940-337-4132
Fax Number	:

Provider Business Practice Location Address
First Line	:	5309 WURZBACH RD STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-2431
Country	:	US
Telephone Number	:	940-337-4132
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	10/31/2024

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