Provider Demographics
NPI:1073155933
Name:GANIYU, BAMIDELE
Entity Type:Individual
Prefix:
First Name:BAMIDELE
Middle Name:
Last Name:GANIYU
Suffix:
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 1:616 DEREK DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-6841
Mailing Address - Country:US
Mailing Address - Phone:314-960-4106
Mailing Address - Fax:
Practice Address - Street 1:2101 CORONA RD STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2582
Practice Address - Country:US
Practice Address - Phone:573-234-1800
Practice Address - Fax:573-234-1799
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020002143363LP0808X, 363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program