Provider Demographics
NPI:1467921122
Name:AGADA, BAMIDELE OMOWUMI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BAMIDELE
Middle Name:OMOWUMI
Last Name:AGADA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:BAMIDELE
Other - Middle Name:OMOWUMI
Other - Last Name:AGADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:327 BEACH 19TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4423
Mailing Address - Country:US
Mailing Address - Phone:718-869-7248
Mailing Address - Fax:
Practice Address - Street 1:13528 231ST ST
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2532
Practice Address - Country:US
Practice Address - Phone:646-331-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-24
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF405177363LP0808X
NY569577-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice