Provider Demographics
NPI:1518373935
Name:OMOROGBE, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:OMOROGBE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 NEW KARNER RD STE 9
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-3882
Mailing Address - Country:US
Mailing Address - Phone:518-246-6649
Mailing Address - Fax:518-246-6657
Practice Address - Street 1:501 NEW KARNER RD STE 9
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-3882
Practice Address - Country:US
Practice Address - Phone:518-246-6649
Practice Address - Fax:518-246-6657
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338879363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily