Provider Demographics
NPI:1700119567
Name:FAJEMISIN, BABAJIDE ADETOKUNBO (PA-C)
Entity type:Individual
Prefix:MR
First Name:BABAJIDE
Middle Name:ADETOKUNBO
Last Name:FAJEMISIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:15791 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1746
Practice Address - Country:US
Practice Address - Phone:760-949-1231
Practice Address - Fax:877-738-3841
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20295363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF:10/29/12Medicaid
CAEFF:10/21/13-VICTORVMedicaid
CAP01288530/DU5182OtherRAILROAD MEDICARE-COLTON/VICTORVILLE
CAP01282519/DU4034OtherRAILROAD MEDICARE-ADELANTO
CAEFF.10/21/13-COLTONMedicaid
CAEFF: 1/24/2013Medicaid
CAEFF: 1/18/13Medicaid
CAEFF: 1/18/2013Medicaid
CAEFF.10/21/13-COLTONMedicaid
CAP01282519/DU4034OtherRAILROAD MEDICARE-ADELANTO