=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134730534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLIN MEDICAL & WELLNESS GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 08/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9400 LAKEVIEW PKWY STE 111
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75088-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-270-7854
-----------------------------------------------------
Fax | 469-329-1044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6841 VIRGINIA PKWY STE 103-307
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75071-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ADEBUKOLA OBASANYA
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 469-270-7854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------