Provider Demographics
NPI:1700473600
Name:MUSTAPHA, LATIF ADEYEMI (NP)
Entity Type:Individual
Prefix:
First Name:LATIF
Middle Name:ADEYEMI
Last Name:MUSTAPHA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8220
Mailing Address - Country:US
Mailing Address - Phone:623-241-2084
Mailing Address - Fax:
Practice Address - Street 1:12025 W APACHE ST
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-8220
Practice Address - Country:US
Practice Address - Phone:623-241-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ250957363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology