Healthcare Provider Details

I. General information

NPI: 1255723797
Provider Name (Legal Business Name): IBUNKUN OLORUNOJE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

IV. Provider business mailing address

450 CLARKSON AVE # ED
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 888-959-5192
  • Fax:
Mailing address:
  • Phone: 718-270-8289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number10313257
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number024382
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: