Provider Demographics
NPI:1225301708
Name:OGUNWO, ADEWALE (NP)
Entity Type:Individual
Prefix:
First Name:ADEWALE
Middle Name:
Last Name:OGUNWO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 BARDOLINO DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-4636
Mailing Address - Country:US
Mailing Address - Phone:910-868-6477
Mailing Address - Fax:
Practice Address - Street 1:1905 SKIBO RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-0260
Practice Address - Country:US
Practice Address - Phone:910-864-4357
Practice Address - Fax:910-221-0099
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005501363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC5209AOtherPTAN