Provider Demographics
NPI:1942861950
Name:BUSARI, ADEWALE MUSILIYU
Entity Type:Individual
Prefix:
First Name:ADEWALE
Middle Name:MUSILIYU
Last Name:BUSARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 S MCCARRAN BLVD STE 14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6129
Mailing Address - Country:US
Mailing Address - Phone:775-393-9101
Mailing Address - Fax:775-403-1799
Practice Address - Street 1:6880 S MCCARRAN BLVD STE 14
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6129
Practice Address - Country:US
Practice Address - Phone:775-393-9101
Practice Address - Fax:775-403-1799
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV823071363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1699018978Medicaid