Provider Demographics
NPI:1972735223
Name:MIKOKU, FADEKE
Entity type:Individual
Prefix:
First Name:FADEKE
Middle Name:
Last Name:MIKOKU
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 1:452 INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4416
Mailing Address - Country:US
Mailing Address - Phone:718-619-5530
Mailing Address - Fax:
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013227363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant