Healthcare Provider Details

I. General information

NPI: 1184033250
Provider Name (Legal Business Name): EDWIN ETSE KWAKUGAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2014
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA RD
GRAND FORKS ND
58201-4036
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201-4183
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-5000
  • Fax: 701-780-1892
Mailing address:
  • Phone: 701-780-4085
  • Fax: 701-780-4477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number14567
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number14567
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14567
License Number StateND
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: