Provider Demographics
NPI:1972196889
Name:ADEYEYE, OLUYOMI M (PA-S)
Entity Type:Individual
Prefix:
First Name:OLUYOMI
Middle Name:M
Last Name:ADEYEYE
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:YOMI
Other - Middle Name:M
Other - Last Name:ADEYEYE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-S
Mailing Address - Street 1:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 COLLIER RD NW STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1740
Practice Address - Country:US
Practice Address - Phone:404-350-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant