Provider Demographics
NPI:1750655353
Name:ABU, OGBANEDI JOHN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:OGBANEDI
Middle Name:JOHN
Last Name:ABU
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:PO BOX 580244
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-0005
Mailing Address - Country:US
Mailing Address - Phone:209-472-6624
Mailing Address - Fax:209-477-1065
Practice Address - Street 1:415 W BENJAMIN HOLT DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3958
Practice Address - Country:US
Practice Address - Phone:209-477-4103
Practice Address - Fax:209-477-1065
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA22087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant