Healthcare Provider Details

I. General information

NPI: 1467597369
Provider Name (Legal Business Name): KWABENA NTIAMOAH PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 FULTON AVE. BRONX LEBANON HOSPITAL DEPT. OF PSYCHIATRY, 1276 FULTON AVE
BRONX NY
10456
US

IV. Provider business mailing address

3924 MONTICELLO AVE
BRONX NY
10466-2422
US

V. Phone/Fax

Practice location:
  • Phone: 718-466-6020
  • Fax: 718-466-6060
Mailing address:
  • Phone: 718-466-6020
  • Fax: 178-466-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5300378
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: