Provider Demographics
NPI:1407910763
Name:ADEWALE, DEBRA CARDELL (PAC)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:CARDELL
Last Name:ADEWALE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-2623
Mailing Address - Country:US
Mailing Address - Phone:213-804-1305
Mailing Address - Fax:323-704-3341
Practice Address - Street 1:7301 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-2254
Practice Address - Country:US
Practice Address - Phone:323-778-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical