Basic Information
| Provider Information | |||||||||
| NPI: | 1972796399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGO-OSUALA | ||||||||
| FirstName: | MEENA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 3013409027 | ||||||||
| Practice Location | |||||||||
| Address1: | 10521 ROSEHAVEN ST STE LL100 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220302877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032815000 | ||||||||
| FaxNumber: | 7032550765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2007 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0003570 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110006185 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-05017 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1972796399 | 05 | NC | MEDICAID | 2586PA | 05 | SC | MEDICAID |