Healthcare Provider Details

I. General information

NPI: 1770108193
Provider Name (Legal Business Name): MARIAH OWUSU-AGYEI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3526 VILLAGE DR
FAYETTEVILLE NC
28304-4554
US

IV. Provider business mailing address

601 N CAROLINE ST
BALTIMORE MD
21287-0006
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-3970
  • Fax: 910-615-9671
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2026-01913
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number71856
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number71856
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: