Provider Demographics
NPI:1114399763
Name:ANYINAM, KWASI D
Entity Type:Individual
Prefix:
First Name:KWASI
Middle Name:D
Last Name:ANYINAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 S HAUPT AVENUE
Mailing Address - Street 2:APT 170
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85634
Mailing Address - Country:US
Mailing Address - Phone:928-246-0956
Mailing Address - Fax:
Practice Address - Street 1:11420 S FORTUNA RD
Practice Address - Street 2:WALGREENS
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-5618
Practice Address - Country:US
Practice Address - Phone:928-246-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZIO11838390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program