Healthcare Provider Details

I. General information

NPI: 1073670469
Provider Name (Legal Business Name): KEHINDE ADEKOYEJO AKINFENWA LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 DICKERSON DR
JASPER TX
75951-5111
US

IV. Provider business mailing address

1006 DICKERSON DR
JASPER TX
75951-5111
US

V. Phone/Fax

Practice location:
  • Phone: 409-383-5200
  • Fax: 409-383-5202
Mailing address:
  • Phone: 409-383-5200
  • Fax: 409-383-5202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1144418
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: