Provider Demographics
NPI:1942972690
Name:MODUPE, OMONIYI TUNDE (DNP-CRNA)
Entity type:Individual
Prefix:
First Name:OMONIYI
Middle Name:TUNDE
Last Name:MODUPE
Suffix:
Gender:M
Credentials:DNP-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:482-886-9358
Mailing Address - Fax:732-790-0107
Practice Address - Street 1:1 COOPER PLZ DEPT OF
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1461
Practice Address - Country:US
Practice Address - Phone:856-342-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN685335367500000X
NJ26NJ15060600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered