Provider Demographics
NPI:1558641746
Name:ABE - LATHAN, MOBOLUWADE DUDUYEMI (PA-C)
Entity Type:Individual
Prefix:
First Name:MOBOLUWADE
Middle Name:DUDUYEMI
Last Name:ABE - LATHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 W WELLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6549
Mailing Address - Country:US
Mailing Address - Phone:952-210-7665
Mailing Address - Fax:
Practice Address - Street 1:2424 ERWIN RD STE 201
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3825
Practice Address - Country:US
Practice Address - Phone:919-668-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0066443363AM0700X
SC1669363A00000X
NC0010-04892363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant