Provider Demographics
NPI:1932749553
Name:ADEREMI-IBITOLA, ADETOKUNBO ATINUKE (PA-C)
Entity Type:Individual
Prefix:
First Name:ADETOKUNBO
Middle Name:ATINUKE
Last Name:ADEREMI-IBITOLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINUKE
Other - Middle Name:
Other - Last Name:ADEREMI-IBITOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11351 RANDOM HILLS RD STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6081
Practice Address - Country:US
Practice Address - Phone:443-351-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061310363A00000X
PAOA005119363A00000X
VA0110009227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant