Healthcare Provider Details

I. General information

NPI: 1255608824
Provider Name (Legal Business Name): ADEOLA FAGBOHUNKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2011
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

2999 LOST CREEK BLVD
LAUREL MD
20724-1971
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8118
  • Fax:
Mailing address:
  • Phone: 301-324-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0004550
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: