1538182936 NPI number — OLADIMEJI OLU SORUNKE PA

Table of content: OLADIMEJI OLU SORUNKE PA (NPI 1538182936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538182936 NPI number — OLADIMEJI OLU SORUNKE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORUNKE
Provider First Name:
OLADIMEJI
Provider Middle Name:
OLU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538182936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-0019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-723-3638
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 W PLEASANT RUN RD STE 215
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75146-1170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-208-9883
Provider Business Practice Location Address Fax Number:
972-223-7688
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA03163 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA03163 . This is a "PHYSICIAN ASSISTANTS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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