Provider Demographics
NPI:1679723274
Name:EMENANJO, OLABISI L (PA-C)
Entity Type:Individual
Prefix:
First Name:OLABISI
Middle Name:L
Last Name:EMENANJO
Suffix:
Gender:F
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:1110 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1602
Practice Address - Country:US
Practice Address - Phone:443-351-3917
Practice Address - Fax:443-351-3918
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030495363A00000X
MDC0003491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD489314YWV2Medicare PIN
MD232273YVZ - 945LMedicare PIN
MD235275ZDDB - 149619Medicare PIN