Basic Information
| Provider Information | |||||||||
| NPI: | 1922430552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SADIQ | ||||||||
| FirstName: | ADETOUN | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 E UNIVERSITY AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786266814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128681124 | ||||||||
| FaxNumber: | 5128689894 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 N A W GRIMES BLVD STE N301A | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786653540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778005722 | ||||||||
| FaxNumber: | 5122181377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2013 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9318860 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | AP127861 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3510455-01 | 05 | TX | MEDICAID | AP127861 | 01 | TX | LICENSE | OTHER |