Healthcare Provider Details

I. General information

NPI: 1639687163
Provider Name (Legal Business Name): OMOLARA OLASIMBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N CHARLES ST
BALTIMORE MD
21204-6808
US

IV. Provider business mailing address

1315 BRETON DR
ELDERSBURG MD
21784-6137
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-2000
  • Fax:
Mailing address:
  • Phone: 410-552-8289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006739
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: