Provider Demographics
NPI:1295214856
Name:ADEBAYO, ADEBISI BOLANLE
Entity Type:Individual
Prefix:
First Name:ADEBISI
Middle Name:BOLANLE
Last Name:ADEBAYO
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 1:9018 HIGH BR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-4411
Mailing Address - Country:US
Mailing Address - Phone:210-571-3344
Mailing Address - Fax:
Practice Address - Street 1:10439 CEDAR VLG
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3114
Practice Address - Country:US
Practice Address - Phone:210-725-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX227729164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKW236704416OtherAETNA