Healthcare Provider Details

I. General information

NPI: 1609321181
Provider Name (Legal Business Name): FISAYO OGUNYOMI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13727 246TH ST
ROSEDALE NY
11422-1838
US

IV. Provider business mailing address

13727 246TH ST
ROSEDALE NY
11422-1838
US

V. Phone/Fax

Practice location:
  • Phone: 917-880-0579
  • Fax:
Mailing address:
  • Phone: 917-880-0579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF341006-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: