Healthcare Provider Details

I. General information

NPI: 1134860208
Provider Name (Legal Business Name): ADETINUKE MOTUNRAYO OGUNLEYE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 FLATBUSH AVE
BROOKLYN NY
11226-3102
US

IV. Provider business mailing address

3479 FORESTDALE DR APT 2A
BURLINGTON NC
27215-8210
US

V. Phone/Fax

Practice location:
  • Phone: 718-571-9372
  • Fax:
Mailing address:
  • Phone: 631-219-3973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001012172
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001012172
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: