MEDICARE: WASIU A OMOTAYO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency
2	376G00000X	Nursing Home Administrator		WI

General Provider Information

NPI Number	:	1194618892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WASIU A OMOTAYO

Provider Business Mailing Address
First Line	:	5414 W VILLARD AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-4224
Country	:	US
Telephone Number	:	414-241-2446
Fax Number	:

Provider Business Practice Location Address
First Line	:	5414 W VILLARD AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-4224
Country	:	US
Telephone Number	:	414-241-2446
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2025
Last Update Date	:	01/18/2026

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Directions to “ WASIU A OMOTAYO ” Practice Location

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