Provider Demographics
NPI:1548443328
Name:AKINTOLA, OMONIYI TEMITOPE (PA C)
Entity type:Individual
Prefix:
First Name:OMONIYI
Middle Name:TEMITOPE
Last Name:AKINTOLA
Suffix:
Gender:M
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 1:6330 LAGUNA VILLA WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4735
Mailing Address - Country:US
Mailing Address - Phone:916-549-9029
Mailing Address - Fax:
Practice Address - Street 1:4001 HWY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-14
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16410363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical