MEDICARE: MR. TOMILOLA WILSON ODUMUWAGUN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	035083-01	NY

General Provider Information

NPI Number	:	1578410346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOMILOLA WILSON ODUMUWAGUN PA-C

Provider Business Mailing Address
First Line	:	760 ELDERT LN APT 4J
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-4234
Country	:	US
Telephone Number	:	917-216-9036
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 N 7TH AVE
Second Line	:
City	:	MOUNT VERNON
State	:	NY
Zip	:	10550-2026
Country	:	US
Telephone Number	:	914-664-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2026
Last Update Date	:	03/11/2026

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