Provider Demographics
NPI:1619740008
Name:OSUNDE, EZEKIEL EHIGIAMUSOE (PA)
Entity Type:Individual
Prefix:DR
First Name:EZEKIEL
Middle Name:EHIGIAMUSOE
Last Name:OSUNDE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 S TELEMACHUS ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-1129
Mailing Address - Country:US
Mailing Address - Phone:507-319-6190
Mailing Address - Fax:
Practice Address - Street 1:1215 AVENUE J
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-4038
Practice Address - Country:US
Practice Address - Phone:507-319-6190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant