Provider Demographics
NPI:1285021121
Name:AJIBOLA, OLUKEMI
Entity Type:Individual
Prefix:
First Name:OLUKEMI
Middle Name:
Last Name:AJIBOLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N53W15851 CREEKWOOD XING
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0610
Mailing Address - Country:US
Mailing Address - Phone:262-844-7757
Mailing Address - Fax:
Practice Address - Street 1:10600 N PORT WASHINGTON RD STE 200
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5084
Practice Address - Country:US
Practice Address - Phone:262-240-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52375363AM0700X
WI7202-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100227402Medicaid