| Noble Parkway Medical Clinic Professional Corporation | |
|
4808 85th Ave North Suite 300 Brooklyn Park MN 55443 | |
| (763) 496-1562 | |
| (763) 657-0581 |
| Full Name | Noble Parkway Medical Clinic Professional Corporation |
|---|---|
| Speciality | Clinic/Center |
| Location | 4808 85th Ave North, Brooklyn Park, Minnesota |
| Authorized Official Name and Position | Tajudeen O Fawole (CEO) |
| Authorized Official Contact | 7634961562 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Noble Parkway Medical Clinic Professional Corporation 4808 85th Ave North Suite 300 Brooklyn Park MN 55443 Ph: (763) 496-1562 | Noble Parkway Medical Clinic Professional Corporation 4808 85th Ave North Suite 300 Brooklyn Park MN 55443 Ph: (763) 496-1562 |
| NPI Number | 1043556517 |
|---|---|
| Provider Enumeration Date | 01/02/2013 |
| Last Update Date | 05/16/2013 |
| Medicare PECOS PAC ID | 8921245689 |
|---|---|
| Medicare Enrollment ID | O20130516000538 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043556517 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Tajudeen O Fawole |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1801991005 PECOS PAC ID: 8729017082 Enrollment ID: I20061023000043 |
| Provider Name | Abejide O Fawole |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1497939565 PECOS PAC ID: 8022192095 Enrollment ID: I20080303000815 |
| Provider Name | Olitha J Fofana |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013301407 PECOS PAC ID: 1254643349 Enrollment ID: I20150701002832 |
| Provider Name | Nkeiruka Sylvia Anyiam |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427425750 PECOS PAC ID: 4486959236 Enrollment ID: I20160216002668 |
| Provider Name | Alade L Hamza |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1144862996 PECOS PAC ID: 6305251471 Enrollment ID: I20210223001758 |
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