Healthcare Provider Details

I. General information

NPI: 1538386495
Provider Name (Legal Business Name): WALE MUYIWA OLUKANMI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. OLUBOWALE OLUMUYIWA OLUKANMI

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44750 60TH ST W
LANCASTER CA
93536-7619
US

IV. Provider business mailing address

PO BOX 1675
LANCASTER CA
93539-1675
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-2000
  • Fax:
Mailing address:
  • Phone: 310-663-3122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA16609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: