Provider Demographics
NPI:1881783934
Name:OSAGIEDE, EKHATOR L (PA-C)
Entity type:Individual
Prefix:
First Name:EKHATOR
Middle Name:L
Last Name:OSAGIEDE
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 1:1145 MARKET ST
Mailing Address - Street 2:FL 10
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1566
Mailing Address - Country:US
Mailing Address - Phone:310-714-0189
Mailing Address - Fax:310-714-0189
Practice Address - Street 1:508 VENICE WAY
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-2810
Practice Address - Country:US
Practice Address - Phone:310-714-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant