Provider Demographics
NPI:1669485579
Name:OKUNSANYA, OLUWOLE ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:OLUWOLE
Middle Name:ANDREW
Last Name:OKUNSANYA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2427 STAUNTON DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5278
Mailing Address - Country:US
Mailing Address - Phone:678-379-4557
Mailing Address - Fax:678-475-3992
Practice Address - Street 1:2427 STAUNTON DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5278
Practice Address - Country:US
Practice Address - Phone:678-379-4557
Practice Address - Fax:678-475-3992
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004091363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582632608OtherTRICARE
GA52126587OtherBLUE CROSS BLUE SHIELD
GA511I970320Medicare PIN