Healthcare Provider Details

I. General information

NPI: 1306175633
Provider Name (Legal Business Name): MR. STEPHEN OLOMUKORO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

11781 LEE JACKSON MEMORIAL HWY SUITE 550
FAIRFAX VA
22033-3309
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-2200
  • Fax:
Mailing address:
  • Phone: 571-777-5157
  • Fax: 703-890-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR152983
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR152983
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: