=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184039760
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADESINA HUSSEIN SANNI M.D;
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2014
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W MINERAL KING AVE
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93291-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-624-6999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26666 PHS PROVIDER ENROLLMENT
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87125-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-923-6770
-----------------------------------------------------
Fax | 505-923-5354
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD2017-0028
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------