Healthcare Provider Details

I. General information

NPI: 1205748415
Provider Name (Legal Business Name): TOMILOLA KOLADE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5481 HUNTER JUMPER LN
APOPKA FL
32712-6083
US

IV. Provider business mailing address

5481 HUNTER JUMPER LN
APOPKA FL
32712-6083
US

V. Phone/Fax

Practice location:
  • Phone: 347-608-7192
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3264-P.A.
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: