Provider Demographics
NPI:1255689824
Name:ADENIRAN, ADEBUKOLA AINA (NP)
Entity Type:Individual
Prefix:
First Name:ADEBUKOLA
Middle Name:AINA
Last Name:ADENIRAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BUKOLA
Other - Middle Name:AINA
Other - Last Name:ADENIRAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:133 E MAIN ST STE 1B
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3517
Mailing Address - Country:US
Mailing Address - Phone:631-482-9880
Mailing Address - Fax:631-482-9911
Practice Address - Street 1:133 E MAIN ST STE 1B
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3517
Practice Address - Country:US
Practice Address - Phone:631-482-9880
Practice Address - Fax:631-482-9911
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553296-1163W00000X
NY306216364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03652600Medicaid