Basic Information
| Provider Information | |||||||||
| NPI: | 1932157294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODUEYUNGBO | ||||||||
| FirstName: | FOLARIN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089234000 | ||||||||
| FaxNumber: | 7089238848 | ||||||||
| Practice Location | |||||||||
| Address1: | 12251 S 80TH AVE | ||||||||
| Address2: | |||||||||
| City: | PALOS HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604631290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089234000 | ||||||||
| FaxNumber: | 7089238848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209005908 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.