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General NPI Number Information
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NPI Number | 1003939968
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Entity Type | Individual
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Provider Name | OLADEPO COLLINS FASORANTI MBBS
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Gender | Male
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Dates
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Enumeration Date | 04/07/2007
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Last Update Date | 12/05/2011
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Provider Practice Location Address
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Address Line | 11475 ROBINSON DRIVE NW - MAILSTOP 32600A HEALTHPARTNERS COON RAPIDS CLINIC
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City | COON RAPIDS
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State | MN
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Zip | 55433-3746
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Country | US
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Telephone | 763-587-9000
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Fax | 763-587-9130
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Provider Business Mailing Address
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Address Line | 8170 33RD AVE S MS21110Q
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City | MINNEAPOLIS
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State | MN
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Zip | 55425-4516
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Country | US
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Telephone | 952-883-5375
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Fax | 763-587-9130
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 001220
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License Number State | GA
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