Healthcare Provider Details

I. General information

NPI: 1316007685
Provider Name (Legal Business Name): ADEPEJU BOLANLE GEORGE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8233 E STOCKTON BLVD STE D
SACRAMENTO CA
95828-8203
US

IV. Provider business mailing address

9999 CORTINO WAY
ELK GROVE CA
95757-3052
US

V. Phone/Fax

Practice location:
  • Phone: 916-368-3080
  • Fax: 916-405-6551
Mailing address:
  • Phone: 916-879-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17876
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: