Provider Demographics
NPI:1386352789
Name:ADEDURO, MICHAEL OLUSEGUN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OLUSEGUN
Last Name:ADEDURO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 VAHAN CT
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-6880
Mailing Address - Country:US
Mailing Address - Phone:661-916-5608
Mailing Address - Fax:
Practice Address - Street 1:4653 VAHAN CT
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-6880
Practice Address - Country:US
Practice Address - Phone:661-916-5608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023296363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health