Provider Demographics
NPI:1326883240
Name:ADETUNJI, BAMIDELE A
Entity type:Individual
Prefix:
First Name:BAMIDELE
Middle Name:A
Last Name:ADETUNJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3399 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3312
Mailing Address - Country:US
Mailing Address - Phone:702-444-0438
Mailing Address - Fax:
Practice Address - Street 1:3399 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3312
Practice Address - Country:US
Practice Address - Phone:702-444-0438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN41231163WG0000X
CA95019581363LF0000X
NV882337363L00000X
CARN656881163WG0000X
NVRN70706163WG0000X
AZRN307537163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily