Provider Demographics
NPI:1114469467
Name:ESAN, ABIDEMI
Entity Type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:
Last Name:ESAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 WHITNEY RANCH DR APT 1625
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2630
Mailing Address - Country:US
Mailing Address - Phone:206-496-3200
Mailing Address - Fax:
Practice Address - Street 1:625 WHITNEY RANCH DR APT 1625
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2630
Practice Address - Country:US
Practice Address - Phone:206-496-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN74080163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid