Provider Demographics
NPI:1831250455
Name:FADOJU, OLUFUNKE E (PA)
Entity type:Individual
Prefix:
First Name:OLUFUNKE
Middle Name:E
Last Name:FADOJU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:O
Other - Last Name:FADOJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:705 DIXIE ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3818
Mailing Address - Country:US
Mailing Address - Phone:678-301-0636
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:678-301-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00158100363A00000X
GA6359363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ122297TS6Medicare PIN