Provider Demographics
NPI:1487165973
Name:EWETUSA, OLUDARE (PTA)
Entity type:Individual
Prefix:
First Name:OLUDARE
Middle Name:
Last Name:EWETUSA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44330 PREMIER PLZ STE 110
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5071
Mailing Address - Country:US
Mailing Address - Phone:703-723-9355
Mailing Address - Fax:
Practice Address - Street 1:44330 PREMIER PLZ STE 110
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5071
Practice Address - Country:US
Practice Address - Phone:703-723-9355
Practice Address - Fax:703-723-9355
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604918225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty