Provider Demographics
NPI:1396378873
Name:KESHINRO, ADEWUSI SAMSON (LPN)
Entity Type:Individual
Prefix:
First Name:ADEWUSI
Middle Name:SAMSON
Last Name:KESHINRO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 E BROADWAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1377
Mailing Address - Country:US
Mailing Address - Phone:215-294-0792
Mailing Address - Fax:
Practice Address - Street 1:64 E BROADWAY RD STE 200
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1377
Practice Address - Country:US
Practice Address - Phone:215-294-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP053643164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse