Provider Demographics
NPI:1548606239
Name:FAMUYIWA, BABATUNDE A (AA)
Entity Type:Individual
Prefix:
First Name:BABATUNDE
Middle Name:A
Last Name:FAMUYIWA
Suffix:
Gender:M
Credentials:AA
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 3559
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0993
Mailing Address - Country:US
Mailing Address - Phone:770-979-9996
Mailing Address - Fax:770-979-1202
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:770-979-9996
Practice Address - Fax:770-979-1202
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA539367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA539OtherSTATE LICENSE