Basic Information
| Provider Information | |||||||||
| NPI: | 1073155933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANIYU | ||||||||
| FirstName: | BAMIDELE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 DEREK DR | ||||||||
| Address2: | |||||||||
| City: | WENTZVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633856841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149604106 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 CORONA RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732341800 | ||||||||
| FaxNumber: | 5732341799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2019 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363LP0808X | 2020002143 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.