Healthcare Provider Details

I. General information

NPI: 1538534599
Provider Name (Legal Business Name): OLUWANIFEMI OLUWATISE OGUNBADEJO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 NEW YORK AVE ROOM 201
BROOKLYN NY
11203-2720
US

IV. Provider business mailing address

811 NEW YORK AVE ROOM 201
BROOKLYN NY
11203-2720
US

V. Phone/Fax

Practice location:
  • Phone: 347-443-5632
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019336
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: