Healthcare Provider Details

I. General information

NPI: 1497525042
Provider Name (Legal Business Name): OLAKUNLE OLOGUN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18511 HIGHLANDER MEDICS ST
FORT BLISS TX
79906-5327
US

IV. Provider business mailing address

11335 SSG SIMS ST
FORT BLISS TX
79918
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: