Provider Demographics
NPI:1730389198
Name:OGUNFIDITIMI, FOLUSHO EVERTON (PA-C)
Entity type:Individual
Prefix:MR
First Name:FOLUSHO
Middle Name:EVERTON
Last Name:OGUNFIDITIMI
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3334 GOAT FELL
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2087
Mailing Address - Country:US
Mailing Address - Phone:313-916-9971
Mailing Address - Fax:313-916-2086
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:2799 WEST GRAND BLVD.
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-9971
Practice Address - Fax:313-916-2086
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
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Provider Licenses
StateLicense IDTaxonomies
MI5601003120363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S84324Medicare UPIN