Provider Demographics
NPI:1104497841
Name:IBERU-OLUSHOGA, OLATUNJI ISMAIL (CRNP)
Entity type:Individual
Prefix:
First Name:OLATUNJI
Middle Name:ISMAIL
Last Name:IBERU-OLUSHOGA
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 FITZPATRICK DR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-3142
Mailing Address - Country:US
Mailing Address - Phone:130-172-8034
Mailing Address - Fax:
Practice Address - Street 1:1509 FITZPATRICK DR
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-3142
Practice Address - Country:US
Practice Address - Phone:130-172-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily