Provider Demographics
NPI:1437670841
Name:FAT-ANTHONY, AJIBOLA (NP)
Entity Type:Individual
Prefix:
First Name:AJIBOLA
Middle Name:
Last Name:FAT-ANTHONY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 QUAIL AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-4276
Mailing Address - Country:US
Mailing Address - Phone:956-802-4662
Mailing Address - Fax:
Practice Address - Street 1:2808 QUAIL AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-4276
Practice Address - Country:US
Practice Address - Phone:956-802-4662
Practice Address - Fax:956-802-4662
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily