MEDICARE: ADETOUN ADESIDA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP140128	TX

General Provider Information

NPI Number	:	1316411390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADETOUN ADESIDA FNP

Provider Business Mailing Address
First Line	:	6500 RIVER PLACE BLVD STE 102
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-1119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16103 W LITTLE YORK RD STE E
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77084-6867
Country	:	US
Telephone Number	:	281-861-0919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	03/12/2019

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