Provider Demographics
NPI:1841581147
Name:BAMIDELE, TOLA E (PA)
Entity Type:Individual
Prefix:
First Name:TOLA
Middle Name:E
Last Name:BAMIDELE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 BILL ELLER DR.
Mailing Address - Street 2:
Mailing Address - City:LAVERN
Mailing Address - State:TN
Mailing Address - Zip Code:37086
Mailing Address - Country:US
Mailing Address - Phone:615-295-4812
Mailing Address - Fax:
Practice Address - Street 1:1465 BEDFORD AVE
Practice Address - Street 2:APT 1 R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-3810
Practice Address - Country:US
Practice Address - Phone:347-486-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304341164W00000X
TN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No164W00000XNursing Service ProvidersLicensed Practical Nurse