Provider Demographics
NPI:1124505615
Name:OMOTOLA, MICHAEL G (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:OMOTOLA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:417 W 20TH ST UNIT 11386
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1287
Mailing Address - Country:US
Mailing Address - Phone:512-363-3257
Mailing Address - Fax:
Practice Address - Street 1:2520 W I 20
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-7280
Practice Address - Country:US
Practice Address - Phone:512-363-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant