Provider Demographics
NPI:1245938307
Name:FAGBODUN, BLAYSON A
Entity type:Individual
Prefix:
First Name:BLAYSON
Middle Name:A
Last Name:FAGBODUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BLAYSON
Other - Middle Name:ROSEMOND
Other - Last Name:KABIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3055 S NELLIS BLVD APT 1034
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7747
Mailing Address - Country:US
Mailing Address - Phone:702-969-3512
Mailing Address - Fax:
Practice Address - Street 1:3055 S NELLIS BLVD APT 1034
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7747
Practice Address - Country:US
Practice Address - Phone:702-969-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist