Provider Demographics
NPI:1053654814
Name:ADEYEYE, GBENGA ADEYEMI (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GBENGA
Middle Name:ADEYEMI
Last Name:ADEYEYE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 GREENE TREE RD
Mailing Address - Street 2:STE 135
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-7108
Mailing Address - Country:US
Mailing Address - Phone:410-486-6173
Mailing Address - Fax:410-559-9460
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:STE 135
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-7108
Practice Address - Country:US
Practice Address - Phone:410-486-6173
Practice Address - Fax:410-559-9460
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05998363A00000X
VA0110004213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10106951POtherSENTARA HEALTH PLAN
VA10106951POtherOPTIMA HEALTH PLAN
VA10112734POtherSENTARA HEALTH PLAN
VA493474OtherBCBSVA
VA1053654814OtherTRICARE PRIME NETWORK
VA178PYOtherBCBSNC
VA10112734POtherOPTIMA HEALTH PLAN
VA1053654814Medicaid
VAP01192419OtherRAILROAD MEDICARE
VA1053654814Medicaid