Provider Demographics
NPI:1053083071
Name:IWUALA, ADAUGO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ADAUGO
Middle Name:
Last Name:IWUALA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7123 BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:LANDOVER HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2131
Mailing Address - Country:US
Mailing Address - Phone:240-422-7735
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY027397OtherLICENSE