Basic Information
| Provider Information | |||||||||
| NPI: | 1063087849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOYOSORE | ||||||||
| FirstName: | OLAWALE | ||||||||
| MiddleName: | NURUDEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 WHIPPLE ST | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807196554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 HIGHWAY 89 NORTH | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2021 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 262277 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | AP143491 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.