Provider Demographics
NPI:1942478995
Name:OLATUNBOSUN, OLUSEGUN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:OLUSEGUN
Middle Name:
Last Name:OLATUNBOSUN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15601 N CONDUIT AVE
Mailing Address - Street 2:APT. #C33
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4300
Mailing Address - Country:US
Mailing Address - Phone:718-755-1034
Mailing Address - Fax:
Practice Address - Street 1:15601 N CONDUIT AVE
Practice Address - Street 2:APT. #C33
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4300
Practice Address - Country:US
Practice Address - Phone:718-755-1034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant