Healthcare Provider Details

I. General information

NPI: 1437390614
Provider Name (Legal Business Name): ADETUNJI OLATUNJI ADEREMI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6974 GATEWAY BLVD E SUITE F
EL PASO TX
79915
US

IV. Provider business mailing address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 915-774-8850
  • Fax: 915-598-3946
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0003876
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06682
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: