Provider Demographics
NPI:1386295574
Name:OKELOLA, EMMANUEL O (PA-C)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:O
Last Name:OKELOLA
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 1:89 W COPELAND DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2002
Mailing Address - Country:US
Mailing Address - Phone:321-841-7550
Mailing Address - Fax:321-841-8185
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-841-7550
Practice Address - Fax:321-841-8185
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112549363A00000X
FLPA9112549363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104577400Medicaid