Provider Demographics
NPI:1053039818
Name:OGUNTADE, TAIWO HASSAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TAIWO
Middle Name:HASSAN
Last Name:OGUNTADE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 THIELMAN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-7511
Mailing Address - Country:US
Mailing Address - Phone:320-237-6882
Mailing Address - Fax:
Practice Address - Street 1:4180 THIELMAN LN
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-7511
Practice Address - Country:US
Practice Address - Phone:320-237-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9350363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health