Provider Demographics
NPI:1730907338
Name:SHOMUYIWA, BASIRAT OLADUNNI
Entity type:Individual
Prefix:
First Name:BASIRAT
Middle Name:OLADUNNI
Last Name:SHOMUYIWA
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 1:1115 HERRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7503
Mailing Address - Country:US
Mailing Address - Phone:678-895-8405
Mailing Address - Fax:
Practice Address - Street 1:1115 HERRINGTON RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7503
Practice Address - Country:US
Practice Address - Phone:678-895-8405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN136389363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty