Healthcare Provider Details

I. General information

NPI: 1508070913
Provider Name (Legal Business Name): FESTUS ADDO AGYEKUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 KEY PKWY STE 102
FREDERICK MD
21702-4496
US

IV. Provider business mailing address

2649 FRONT SHED DR
FREDERICK MD
21702-2839
US

V. Phone/Fax

Practice location:
  • Phone: 240-215-1138
  • Fax: 240-215-1140
Mailing address:
  • Phone: 240-215-1138
  • Fax: 240-215-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002903
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: