Provider Demographics
NPI:1275981748
Name:MAWUSSI, KOMI
Entity Type:Individual
Prefix:
First Name:KOMI
Middle Name:
Last Name:MAWUSSI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KOMI
Other - Middle Name:
Other - Last Name:MAWUSSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:6271 DREW DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4636
Mailing Address - Country:US
Mailing Address - Phone:757-214-3333
Mailing Address - Fax:
Practice Address - Street 1:6271 DREW DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4636
Practice Address - Country:US
Practice Address - Phone:757-214-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00241734667367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered