Basic Information
| Provider Information | |||||||||
| NPI: | 1205467537 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRANLOYE | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | OLATUNDUN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2225 VATICAN LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752244719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143333393 | ||||||||
| FaxNumber: | 2143330809 | ||||||||
| Practice Location | |||||||||
| Address1: | 2225 VATICAN LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752244719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143333393 | ||||||||
| FaxNumber: | 2143330809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP144638 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | AP144638 | 05 | TX | MEDICAID |