Provider Demographics
NPI:1538386495
Name:OLUKANMI, WALE MUYIWA (PA-C)
Entity type:Individual
Prefix:MR
First Name:WALE
Middle Name:MUYIWA
Last Name:OLUKANMI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:OLUBOWALE
Other - Middle Name:OLUMUYIWA
Other - Last Name:OLUKANMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1675
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-1675
Mailing Address - Country:US
Mailing Address - Phone:310-663-3122
Mailing Address - Fax:
Practice Address - Street 1:44750 60TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-7619
Practice Address - Country:US
Practice Address - Phone:661-729-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16609363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8Z606ZMedicare PIN