Basic Information
| Provider Information | |||||||||
| NPI: | 1811071608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EWEBIYI | ||||||||
| FirstName: | OLUSOLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S COLUMBUS BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191475510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153394747 | ||||||||
| FaxNumber: | 2153395615 | ||||||||
| Practice Location | |||||||||
| Address1: | 6514 MEADOWRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210756115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552478474 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP123676 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.