Provider Demographics
NPI:1700201241
Name:GBADEBO, TAIWO (APN)
Entity type:Individual
Prefix:
First Name:TAIWO
Middle Name:
Last Name:GBADEBO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-751-2300
Mailing Address - Fax:856-751-2333
Practice Address - Street 1:502 CENTENNIAL BLVD STE 3
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9544
Practice Address - Country:US
Practice Address - Phone:856-751-2300
Practice Address - Fax:856-751-2333
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NR13633700363LF0000X
PASP012781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0410217Medicaid