Provider Demographics
NPI:1972796399
Name:EGO-OSUALA, MEENA S (PA-C)
Entity type:Individual
Prefix:
First Name:MEENA
Middle Name:S
Last Name:EGO-OSUALA
Suffix:
Gender:F
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 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:301-340-8339
Mailing Address - Fax:301-340-9027
Practice Address - Street 1:10521 ROSEHAVEN ST STE LL100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2877
Practice Address - Country:US
Practice Address - Phone:703-281-5000
Practice Address - Fax:703-255-0765
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003570363A00000X
VA0110006185363A00000X
NC0010-05017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1972796399Medicaid
SC2586PAMedicaid
NCNCL846AMedicare PIN
NCNCL846BMedicare UPIN
SC2586PAMedicaid