Provider Demographics
NPI:1538182936
Name:SORUNKE, OLADIMEJI OLU (PA)
Entity type:Individual
Prefix:
First Name:OLADIMEJI
Middle Name:OLU
Last Name:SORUNKE
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:PO BOX 2022
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-0019
Mailing Address - Country:US
Mailing Address - Phone:817-723-3638
Mailing Address - Fax:
Practice Address - Street 1:2500 W PLEASANT RUN RD STE 215
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1170
Practice Address - Country:US
Practice Address - Phone:214-208-9883
Practice Address - Fax:972-223-7688
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA03163OtherPHYSICIAN ASSISTANTS
TXPA03163OtherPHYSICIAN ASSISTANTS
TXQ11249Medicare UPIN
TX8K0910Medicare PIN
TX8K0911Medicare PIN