Provider Demographics
NPI:1902543374
Name:OPANUGA, OLUWAGBENGA MICHAEL (APRN - PMHN)
Entity type:Individual
Prefix:
First Name:OLUWAGBENGA
Middle Name:MICHAEL
Last Name:OPANUGA
Suffix:
Gender:M
Credentials:APRN - PMHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 SIMPLY SPOT
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4779
Mailing Address - Country:US
Mailing Address - Phone:210-941-6877
Mailing Address - Fax:
Practice Address - Street 1:5228 S STATE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7058
Practice Address - Country:US
Practice Address - Phone:210-941-6877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95280648163WP0809X
NM81552363LP0808X
WAAP61637881363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult