Healthcare Provider Details

I. General information

NPI: 1700119567
Provider Name (Legal Business Name): BABAJIDE ADETOKUNBO FAJEMISIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 11/27/2023
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15791 BEAR VALLEY RD
HESPERIA CA
92345-1746
US

IV. Provider business mailing address

625 FAIR OAKS AVE STE 270
SOUTH PASADENA CA
91030-5801
US

V. Phone/Fax

Practice location:
  • Phone: 760-949-1231
  • Fax: 877-738-3841
Mailing address:
  • Phone: 626-346-2455
  • Fax: 626-639-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20295
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: