Provider Demographics
NPI:1942605779
Name:OMOREGIE, OSAYANDE ABRAHAM (PA-C)
Entity type:Individual
Prefix:
First Name:OSAYANDE
Middle Name:ABRAHAM
Last Name:OMOREGIE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD STE 148C
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2366
Mailing Address - Country:US
Mailing Address - Phone:615-972-1100
Mailing Address - Fax:615-537-4950
Practice Address - Street 1:3443 DICKERSON PIKE STE 730
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37207-2527
Practice Address - Country:US
Practice Address - Phone:615-972-1100
Practice Address - Fax:615-537-4950
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2646363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016673Medicaid