Provider Demographics
NPI:1639370356
Name:ADENUGA, PAMELA OLABISI
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:OLABISI
Last Name:ADENUGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 SOUTHEAST PKWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-3605
Mailing Address - Country:US
Mailing Address - Phone:817-557-1668
Mailing Address - Fax:888-441-6930
Practice Address - Street 1:1901 SOUTHEAST PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-3605
Practice Address - Country:US
Practice Address - Phone:817-557-1668
Practice Address - Fax:888-441-6930
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32015808465332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3-20158-0846-5OtherSALES AND USE TAX
TX6063680001Medicare NSC