Provider Demographics
NPI:1437390614
Name:ADEREMI, ADETUNJI OLATUNJI (PA)
Entity Type:Individual
Prefix:
First Name:ADETUNJI
Middle Name:OLATUNJI
Last Name:ADEREMI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:6974 GATEWAY BLVD E
Practice Address - Street 2:SUITE F
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915
Practice Address - Country:US
Practice Address - Phone:915-774-8850
Practice Address - Fax:915-598-3946
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003876363AM0700X
TXPA06682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39376214Medicaid
TX313608701Medicaid
TX267432YKN5Medicare PIN