Provider Demographics
NPI:1508491242
Name:ADEGOKE, ANTHONY OLUSOLA
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:OLUSOLA
Last Name:ADEGOKE
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 1:412 MINGOCREST DR
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6700
Mailing Address - Country:US
Mailing Address - Phone:919-601-2033
Mailing Address - Fax:
Practice Address - Street 1:412 MINGOCREST DR
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6700
Practice Address - Country:US
Practice Address - Phone:919-601-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011833363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner