Provider Demographics
NPI:1376977199
Name:AGBOTTAH, EMMANUEL TETTEH (FNP)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:TETTEH
Last Name:AGBOTTAH
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3825
Mailing Address - Country:US
Mailing Address - Phone:781-396-4770
Mailing Address - Fax:
Practice Address - Street 1:85 HIGH ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3825
Practice Address - Country:US
Practice Address - Phone:781-396-4770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA282680363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily