Basic Information
Provider Information | |||||||||
NPI: | 1598113441 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLUSANYA | ||||||||
FirstName: | BUKOLA | ||||||||
MiddleName: | DEBORAH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AWOSANYA | ||||||||
OtherFirstName: | BUKOLA | ||||||||
OtherMiddleName: | DEBORAH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 960 W 62ND PL | ||||||||
Address2: | APT. 243 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900445474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3234409196 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 808 W 58TH ST | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900373632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235411600 | ||||||||
FaxNumber: | 3235411499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2016 | ||||||||
LastUpdateDate: | 09/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95004381 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.