=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902422686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OWOTUTU YEWANDE OLUWASUJI PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2020
-----------------------------------------------------
Last Update Date | 06/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3367 STAGS LEAP DR
-----------------------------------------------------
City | FINKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21048-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-441-9076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3367 STAGS LEAP DR
-----------------------------------------------------
City | FINKSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21048-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-441-9076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A4154
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------