Healthcare Provider Details

I. General information

NPI: 1881991339
Provider Name (Legal Business Name): JIDE OMOSEWO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E MOCKINGBIRD LN SUITE 101
VICTORIA TX
77904-2155
US

IV. Provider business mailing address

1501 E MOCKINGBIRD LN SUITE 101
VICTORIA TX
77904-2155
US

V. Phone/Fax

Practice location:
  • Phone: 361-573-6291
  • Fax: 361-576-2434
Mailing address:
  • Phone: 361-573-6291
  • Fax: 361-576-2434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024169214
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1477
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number869357
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: