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General NPI Number Information
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NPI Number | 1255644423
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Entity Type | Individual
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Provider Name | OLUKEMI ANTONIA MOREIRA-WILSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/16/2010
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Last Update Date | 09/29/2021
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Provider Practice Location Address
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Address Line | 9135 PISCATAWAY RD STE 300
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City | CLINTON
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State | MD
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Zip | 20735-2554
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Country | US
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Telephone | 800-910-1742
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Fax |
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Provider Business Mailing Address
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Address Line | 5306 BROADWATER ST
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City | TEMPLE HILLS
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State | MD
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Zip | 20748-5871
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Country | US
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Telephone | 202-425-0740
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA031357
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110003287
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C0004263
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License Number State | MD
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