Provider Demographics
NPI:1568700979
Name:ADETIBA, BOLAJI KEHINDE (MSN-ANP)
Entity Type:Individual
Prefix:
First Name:BOLAJI
Middle Name:KEHINDE
Last Name:ADETIBA
Suffix:
Gender:F
Credentials:MSN-ANP
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 2932
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85366-2401
Mailing Address - Country:US
Mailing Address - Phone:928-276-4477
Mailing Address - Fax:928-276-4481
Practice Address - Street 1:9 MEDICAL PKWY
Practice Address - Street 2:STE 308
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7858
Practice Address - Country:US
Practice Address - Phone:972-888-7240
Practice Address - Fax:972-888-7285
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX731957363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX273196YKY6Medicare PIN