Provider Demographics
NPI:1659061323
Name:AKWANGA, EDWIN TAJI (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:TAJI
Last Name:AKWANGA
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S SECOND ST STE B
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5898
Mailing Address - Country:US
Mailing Address - Phone:325-260-6726
Mailing Address - Fax:
Practice Address - Street 1:1500 S SECOND ST STE B
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5898
Practice Address - Country:US
Practice Address - Phone:325-260-6726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM73651363LP0808X
TX1117773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health