Provider Demographics
NPI:1427881010
Name:ADEWUMI, OLUTAYO O (PA)
Entity type:Individual
Prefix:
First Name:OLUTAYO
Middle Name:O
Last Name:ADEWUMI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 FAIRMONT DR APT 412
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3757
Mailing Address - Country:US
Mailing Address - Phone:240-486-7471
Mailing Address - Fax:
Practice Address - Street 1:131 JENNIFER RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3043
Practice Address - Country:US
Practice Address - Phone:240-486-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical