Provider Demographics
NPI:1255644423
Name:MOREIRA-WILSON, OLUKEMI ANTONIA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:OLUKEMI
Middle Name:ANTONIA
Last Name:MOREIRA-WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:OLUKEMI
Other - Middle Name:ANTONIA
Other - Last Name:MOREIRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5306 BROADWATER ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-5871
Mailing Address - Country:US
Mailing Address - Phone:202-425-0740
Mailing Address - Fax:
Practice Address - Street 1:9135 PISCATAWAY RD STE 300
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2554
Practice Address - Country:US
Practice Address - Phone:800-910-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031357363A00000X
VA0110003287363A00000X
MDC0004263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant