Provider Demographics
NPI:1972964401
Name:OJEBIYI, OLUYOMBO OJO (PA-C)
Entity Type:Individual
Prefix:
First Name:OLUYOMBO
Middle Name:OJO
Last Name:OJEBIYI
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 1:16245 DESERT KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4011
Mailing Address - Country:US
Mailing Address - Phone:760-955-9555
Mailing Address - Fax:760-955-8558
Practice Address - Street 1:16245 DESERT KNOLL DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4011
Practice Address - Country:US
Practice Address - Phone:760-955-9555
Practice Address - Fax:760-955-8558
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53583363AM0700X
CA53583363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical