Provider Demographics
NPI:1114103470
Name:OMOLADE, ADEFUNKE F (RN, CRNA)
Entity Type:Individual
Prefix:MS
First Name:ADEFUNKE
Middle Name:F
Last Name:OMOLADE
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:ADEFUNKE
Other - Middle Name:F
Other - Last Name:GBADEBO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 WOODS RD
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1530
Mailing Address - Country:US
Mailing Address - Phone:914-493-7000
Mailing Address - Fax:914-493-8439
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7000
Practice Address - Fax:914-493-8439
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY449949367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400010417Medicare PIN
NYG400044153Medicare PIN