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General NPI Number Information
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NPI Number | 1467001859
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Entity Type | Individual
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Provider Name | TIMOTHY OMOTAYO ADESANYA
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Gender | Male
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Dates
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Enumeration Date | 09/09/2019
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Last Update Date | 09/09/2019
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Provider Practice Location Address
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Address Line | GRAHAM CORRECTIONAL CENTER 12078 ILLINOIS RTE 185
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City | HILLIBORO
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State | IL
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Zip | 62049
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Country | US
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Telephone | 217-532-6961
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 512
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City | GREENVILLE
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State | IL
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Zip | 62246-0512
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Country | US
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Telephone | 618-664-2914
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085001089
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License Number State | IL
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