Provider Demographics
NPI:1184033250
Name:KWAKUGAH, EDWIN ETSE (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:ETSE
Last Name:KWAKUGAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4183
Mailing Address - Country:US
Mailing Address - Phone:701-780-4085
Mailing Address - Fax:701-780-4477
Practice Address - Street 1:1200 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4036
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-780-1892
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
ND14567390200000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program