Provider Demographics
NPI:1578577672
Name:BANKOLE, AYO K (ND, PA)
Entity Type:Individual
Prefix:DR
First Name:AYO
Middle Name:K
Last Name:BANKOLE
Suffix:
Gender:M
Credentials:ND, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 N MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786
Mailing Address - Country:US
Mailing Address - Phone:909-981-9200
Mailing Address - Fax:909-982-9220
Practice Address - Street 1:314 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-981-9200
Practice Address - Fax:909-982-9220
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14919363A00000X
CAND-161175F00000X
CAPA-14919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant