Healthcare Provider Details

I. General information

NPI: 1225301708
Provider Name (Legal Business Name): ADEWALE OGUNWO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 SKIBO RD
FAYETTEVILLE NC
28314-0260
US

IV. Provider business mailing address

2732 BARDOLINO DR
FAYETTEVILLE NC
28306-4636
US

V. Phone/Fax

Practice location:
  • Phone: 910-864-4357
  • Fax: 910-221-0099
Mailing address:
  • Phone: 910-868-6477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5005501
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: