Provider Demographics
NPI:1063842367
Name:AGBODZIE, KOMI N (CRNA)
Entity Type:Individual
Prefix:
First Name:KOMI
Middle Name:N
Last Name:AGBODZIE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:800-374-5326
Mailing Address - Fax:800-374-7656
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-5000
Practice Address - Fax:316-291-4272
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS557215367500000X
MO2009029315163W00000X
KS13109541081163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110017092Medicare PIN