Provider Demographics
NPI:1164934956
Name:ABAM, GODWIN A
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:A
Last Name:ABAM
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 1:4543 LAKE OTIS PKWY APT 110
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-1443
Mailing Address - Country:US
Mailing Address - Phone:907-764-1972
Mailing Address - Fax:
Practice Address - Street 1:4543 LAKE OTIS PKWY APT 110
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1443
Practice Address - Country:US
Practice Address - Phone:907-764-1972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management