Provider Demographics
NPI:1538853270
Name:OYEFUSI, MARYAM OLASADE (PA-C)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:OLASADE
Last Name:OYEFUSI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARYAMA
Other - Middle Name:OLASADE
Other - Last Name:OYEFUSI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1200 W TABOR RD FL 4
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3019
Mailing Address - Country:US
Mailing Address - Phone:251-456-3815
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD STE 3006
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7979
Practice Address - Fax:215-456-8539
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical