Provider Demographics
NPI:1376092247
Name:ODERINDE, ADEWALE ANTHONY (NP)
Entity Type:Individual
Prefix:MR
First Name:ADEWALE
Middle Name:ANTHONY
Last Name:ODERINDE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 BLUE BONNET TRL
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3759
Mailing Address - Country:US
Mailing Address - Phone:478-284-6452
Mailing Address - Fax:478-225-6609
Practice Address - Street 1:503 BLUE BONNET TRL
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3759
Practice Address - Country:US
Practice Address - Phone:478-284-6452
Practice Address - Fax:478-225-6609
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184424363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner