Provider Demographics
NPI:1962229070
Name:SHOKUNBI, BUKOLA
Entity type:Individual
Prefix:
First Name:BUKOLA
Middle Name:
Last Name:SHOKUNBI
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 1:4150 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3255
Mailing Address - Country:US
Mailing Address - Phone:612-598-0939
Mailing Address - Fax:
Practice Address - Street 1:4150 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3255
Practice Address - Country:US
Practice Address - Phone:612-598-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR55659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered