Provider Demographics
NPI:1467001859
Name:ADESANYA, TIMOTHY OMOTAYO
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:OMOTAYO
Last Name:ADESANYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-0512
Mailing Address - Country:US
Mailing Address - Phone:618-664-2914
Mailing Address - Fax:
Practice Address - Street 1:GRAHAM CORRECTIONAL CENTER
Practice Address - Street 2:12078 ILLINOIS RTE 185
Practice Address - City:HILLIBORO
Practice Address - State:IL
Practice Address - Zip Code:62049
Practice Address - Country:US
Practice Address - Phone:217-532-6961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001089363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical