Provider Demographics
NPI:1699081315
Name:GOLD, OMOBOLA DENISE (PA)
Entity type:Individual
Prefix:
First Name:OMOBOLA
Middle Name:DENISE
Last Name:GOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3021 OGILVY CT
Mailing Address - Street 2:103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-7615
Mailing Address - Country:US
Mailing Address - Phone:919-596-3400
Mailing Address - Fax:919-596-3499
Practice Address - Street 1:7780 BRIER CREEK PKWY
Practice Address - Street 2:200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7849
Practice Address - Country:US
Practice Address - Phone:919-596-3400
Practice Address - Fax:919-596-3499
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA06578363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical