Provider Demographics
NPI:1912919044
Name:AJIBULU, ADETOKUNBO (PA)
Entity Type:Individual
Prefix:MR
First Name:ADETOKUNBO
Middle Name:
Last Name:AJIBULU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 STOCKHOLM ST
Mailing Address - Street 2:C/O FACULTY PRACTICE MANAGEMENT SUITE I-37 NORTH
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4006
Mailing Address - Country:US
Mailing Address - Phone:718-963-6551
Mailing Address - Fax:
Practice Address - Street 1:11949 UNION TPKE
Practice Address - Street 2:APT # 5D
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6151
Practice Address - Country:US
Practice Address - Phone:646-321-6197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010505363A00000X
VA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical