Healthcare Provider Details

I. General information

NPI: 1033801832
Provider Name (Legal Business Name): TIMOTHY OLUKANNI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

IV. Provider business mailing address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-6952
  • Fax:
Mailing address:
  • Phone: 864-560-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA2000047
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number789789819
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number171
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: