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General NPI Number Information
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NPI Number | 1104497841
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Entity Type | Individual
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Provider Name | OLATUNJI ISMAIL IBERU-OLUSHOGA CRNP
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Gender | Male
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Dates
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Enumeration Date | 07/04/2021
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Last Update Date | 07/04/2021
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Provider Practice Location Address
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Address Line | 1509 FITZPATRICK DR
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City | SEVERN
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State | MD
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Zip | 21144-3142
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Country | US
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Telephone | 130-172-8034
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Fax |
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Provider Business Mailing Address
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Address Line | 1509 FITZPATRICK DR
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City | SEVERN
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State | MD
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Zip | 21144-3142
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Country | US
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Telephone | 130-172-8034
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R214785
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License Number State | MD
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