Basic Information
| Provider Information | |||||||||
| NPI: | 1174089239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADEJUWON | ||||||||
| FirstName: | ADEBOLA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK ROAD | ||||||||
| Address2: | EXECUTIVE PLAZA 1 SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210316446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 CRAIN HWY S STE 301 | ||||||||
| Address2: | |||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210616446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1407878315 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2019 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN1033944 | DC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R220058 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.