Healthcare Provider Details

I. General information

NPI: 1669485579
Provider Name (Legal Business Name): OLUWOLE ANDREW OKUNSANYA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9000
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number004091
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: