Healthcare Provider Details

I. General information

NPI: 1285192963
Provider Name (Legal Business Name): TAIWO OKUBANJO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 SENECA DR
FORT WORTH TX
76137-6141
US

IV. Provider business mailing address

4601 SENECA DR
FORT WORTH TX
76137-6141
US

V. Phone/Fax

Practice location:
  • Phone: 682-556-1274
  • Fax:
Mailing address:
  • Phone: 682-556-1274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP139920
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: