Provider Demographics
NPI:1316007685
Name:GEORGE, ADEPEJU BOLANLE (PA)
Entity Type:Individual
Prefix:MRS
First Name:ADEPEJU
Middle Name:BOLANLE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9999 CORTINO WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3052
Mailing Address - Country:US
Mailing Address - Phone:916-879-4157
Mailing Address - Fax:
Practice Address - Street 1:8233 E STOCKTON BLVD STE D
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-8203
Practice Address - Country:US
Practice Address - Phone:916-368-3080
Practice Address - Fax:916-405-6551
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17876363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17876Medicaid
CAPA17876Medicaid