Provider Demographics
NPI:1962093781
Name:KOLEOSHO, DAUD BIOLA
Entity type:Individual
Prefix:
First Name:DAUD
Middle Name:BIOLA
Last Name:KOLEOSHO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1806
Mailing Address - Country:US
Mailing Address - Phone:480-718-5400
Mailing Address - Fax:877-666-4624
Practice Address - Street 1:1840 E BASELINE RD STE A1
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1527
Practice Address - Country:US
Practice Address - Phone:480-718-5400
Practice Address - Fax:877-666-4624
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ253415363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily