Healthcare Provider Details

I. General information

NPI: 1508739681
Provider Name (Legal Business Name): TAIWO OLAWUYI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 S SAN JACINTO AVE STE A-D&F
SAN JACINTO CA
92583-5103
US

IV. Provider business mailing address

1695 S SAN JACINTO AVE STE A-D&F
SAN JACINTO CA
92583-5103
US

V. Phone/Fax

Practice location:
  • Phone: 951-330-3100
  • Fax: 951-350-1050
Mailing address:
  • Phone: 951-330-3100
  • Fax: 951-350-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: