Basic Information
| Provider Information | |||||||||
| NPI: | 1700119567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAJEMISIN | ||||||||
| FirstName: | BABAJIDE | ||||||||
| MiddleName: | ADETOKUNBO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 15791 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923451746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609491231 | ||||||||
| FaxNumber: | 8777383841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2009 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20295 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | EFF:10/29/12 | 05 | CA | MEDICAID | EFF:10/21/13-VICTORV | 05 | CA | MEDICAID | P01288530/DU5182 | 01 | CA | RAILROAD MEDICARE-COLTON/VICTORVILLE | OTHER | P01282519/DU4034 | 01 | CA | RAILROAD MEDICARE-ADELANTO | OTHER | EFF.10/21/13-COLTON | 05 | CA | MEDICAID | EFF: 1/24/2013 | 05 | CA | MEDICAID | EFF: 1/18/13 | 05 | CA | MEDICAID | EFF: 1/18/2013 | 05 | CA | MEDICAID |