Provider Demographics
NPI:1730553421
Name:ADEGBOYEGA, OMOSALEWA
Entity type:Individual
Prefix:
First Name:OMOSALEWA
Middle Name:
Last Name:ADEGBOYEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3775 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2133
Mailing Address - Country:US
Mailing Address - Phone:318-562-3366
Mailing Address - Fax:318-588-7945
Practice Address - Street 1:3775 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2133
Practice Address - Country:US
Practice Address - Phone:318-562-3366
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily