Healthcare Provider Details

I. General information

NPI: 1487066726
Provider Name (Legal Business Name): YAW OWUSU-POKU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5407 FALLRIVER ROW CT
COLUMBIA MD
21044-2211
US

IV. Provider business mailing address

5407 FALLRIVER ROW CT
COLUMBIA MD
21044-2211
US

V. Phone/Fax

Practice location:
  • Phone: 443-760-6842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC05351
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: