Provider Demographics
NPI:1366985251
Name:ADEWALE, OMOTARA JOAN (MSN, NP-C, FNP-BC)
Entity type:Individual
Prefix:
First Name:OMOTARA
Middle Name:JOAN
Last Name:ADEWALE
Suffix:
Gender:F
Credentials:MSN, NP-C, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:212-639-2000
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:646-465-4656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341251-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily