Healthcare Provider Details

I. General information

NPI: 1013679273
Provider Name (Legal Business Name): AYUK B ETANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 TROY SCHENECTADY RD STE 100
LATHAM NY
12110-1075
US

IV. Provider business mailing address

22 PARK LN S APT 5
MENANDS NY
12204-1922
US

V. Phone/Fax

Practice location:
  • Phone: 518-348-3176
  • Fax:
Mailing address:
  • Phone: 518-250-8685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR263000
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF347994-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: