Healthcare Provider Details

I. General information

NPI: 1104880244
Provider Name (Legal Business Name): MICHELLE D OGUNWALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LILLINGTON AVE SUITE 101
CHARLOTTE NC
28204-3189
US

IV. Provider business mailing address

320 LILLINGTON AVE SUITE 101
CHARLOTTE NC
28204-3189
US

V. Phone/Fax

Practice location:
  • Phone: 704-362-4403
  • Fax: 704-362-4405
Mailing address:
  • Phone: 704-362-4403
  • Fax: 704-362-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01998
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: