Basic Information
| Provider Information | |||||||||
| NPI: | 1992142566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADEBAYO | ||||||||
| FirstName: | OMOTOLA | ||||||||
| MiddleName: | ADUKE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ADEBAYO | ||||||||
| OtherFirstName: | OMOTOL | ||||||||
| OtherMiddleName: | ADUKE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1774 BOXWOOD DR NW | ||||||||
| Address2: | |||||||||
| City: | ACWORTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301023579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708514003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 106 RAM CAT ALY | ||||||||
| Address2: | |||||||||
| City: | SENECA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296783244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648884445 | ||||||||
| FaxNumber: | 8648884345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 03/12/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 18531 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 174H00000X | RN | GA | N | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | GP4697 | 05 | SC | MEDICAID |