Provider Demographics
NPI:1386002251
Name:TAIWO, OLAMIDE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLAMIDE
Middle Name:
Last Name:TAIWO
Suffix:
Gender:M
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 1:17936 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-2240
Mailing Address - Country:US
Mailing Address - Phone:708-623-9732
Mailing Address - Fax:
Practice Address - Street 1:2800 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-5107
Practice Address - Country:US
Practice Address - Phone:773-674-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant