Provider Demographics
NPI:1568941797
Name:ADEGORUSI, MOTUNRAYO OMOLOYE
Entity type:Individual
Prefix:
First Name:MOTUNRAYO
Middle Name:OMOLOYE
Last Name:ADEGORUSI
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 1:11112 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9454
Mailing Address - Country:US
Mailing Address - Phone:240-432-7017
Mailing Address - Fax:
Practice Address - Street 1:9211 CORPORATE BLVD STE 270
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3856
Practice Address - Country:US
Practice Address - Phone:240-559-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196811363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN92802OtherCDS
MDMA4703484OtherDEA