Provider Demographics
NPI:1992142566
Name:ADEBAYO, OMOTOLA ADUKE (NP)
Entity type:Individual
Prefix:MRS
First Name:OMOTOLA
Middle Name:ADUKE
Last Name:ADEBAYO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:OMOTOL
Other - Middle Name:ADUKE
Other - Last Name:ADEBAYO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1774 BOXWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-3579
Mailing Address - Country:US
Mailing Address - Phone:770-851-4003
Mailing Address - Fax:
Practice Address - Street 1:106 RAM CAT ALY
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-3244
Practice Address - Country:US
Practice Address - Phone:864-888-4445
Practice Address - Fax:864-888-4345
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18531363AM0700X
GARN174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4697Medicaid
SCGP4697Medicaid