Basic Information
| Provider Information | |||||||||
| NPI: | 1669994323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILOGHO | ||||||||
| FirstName: | OLUSHOLA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7007 HARBOUR VIEW BLVD STE 108 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234353657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572152784 | ||||||||
| FaxNumber: | 7572152728 | ||||||||
| Practice Location | |||||||||
| Address1: | 3636 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573982285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110005802 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.