Provider Demographics
NPI:1003472309
Name:ADAGBADA, YEKEEN JR
Entity Type:Individual
Prefix:DR
First Name:YEKEEN
Middle Name:
Last Name:ADAGBADA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11049 MAGNOLIA BLVD APT 302
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-5654
Mailing Address - Country:US
Mailing Address - Phone:773-412-8828
Mailing Address - Fax:
Practice Address - Street 1:11049 MAGNOLIA BLVD APT 302
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91601-5654
Practice Address - Country:US
Practice Address - Phone:773-412-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95011775Medicaid