Healthcare Provider Details

I. General information

NPI: 1144772542
Provider Name (Legal Business Name): DR. TAIBAT GBADAMOSI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 HARDING CT
JACKSON NJ
08527-3444
US

IV. Provider business mailing address

306 HARDING CT
JACKSON NJ
08527-3444
US

V. Phone/Fax

Practice location:
  • Phone: 908-670-2311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP016714
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: