Provider Demographics
NPI:1861921900
Name:MOBOLAJI, BOLA T (CRNP)
Entity type:Individual
Prefix:
First Name:BOLA
Middle Name:T
Last Name:MOBOLAJI
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 PHILIPSBURG BIGLER HWY
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-8251
Mailing Address - Country:US
Mailing Address - Phone:203-606-3335
Mailing Address - Fax:
Practice Address - Street 1:1169 PHILIPSBURG BIGLER HWY
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-8251
Practice Address - Country:US
Practice Address - Phone:203-606-3335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-11
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017427363LP2300X
PASP023111363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP017427Medicaid