Healthcare Provider Details

I. General information

NPI: 1811071608
Provider Name (Legal Business Name): OLUSOLA EWEBIYI APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6514 MEADOWRIDGE RD
ELKRIDGE MD
21075-6115
US

IV. Provider business mailing address

1500 S COLUMBUS BLVD
PHILADELPHIA PA
19147-5510
US

V. Phone/Fax

Practice location:
  • Phone: 855-247-8474
  • Fax:
Mailing address:
  • Phone: 215-339-4747
  • Fax: 215-339-5615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP123676
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: