Healthcare Provider Details

I. General information

NPI: 1679723274
Provider Name (Legal Business Name): OLABISI L EMENANJO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2008
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 ANNAPOLIS RD
ODENTON MD
21113-1602
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 443-351-3917
  • Fax: 443-351-3918
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030495
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003491
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: