Provider Demographics
NPI:1821310426
Name:OMONUWA, AMITHA BENA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMITHA
Middle Name:BENA
Last Name:OMONUWA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9960
Mailing Address - Fax:239-424-4006
Practice Address - Street 1:708 DEL PRADO BLVD S STE 3
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2676
Practice Address - Country:US
Practice Address - Phone:239-343-9960
Practice Address - Fax:239-424-4006
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA354613564AMedicaid
FL019421700Medicaid
GA354613564BMedicaid
GA551847OtherWELLCARE
GA01348305OtherAMERIGROUP