Basic Information
| Provider Information | |||||||||
| NPI: | 1255608824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAGBOHUNKA | ||||||||
| FirstName: | ADEOLA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2999 LOST CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207241971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013241282 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8118 GOOD LUCK RD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207063574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015528118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2011 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | C0004550 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.