Provider Demographics
NPI:1679804801
Name:EKANEWANG, PRIMO S
Entity Type:Individual
Prefix:
First Name:PRIMO
Middle Name:S
Last Name:EKANEWANG
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 1:3098 ARBORSYE CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-9102
Mailing Address - Country:US
Mailing Address - Phone:614-678-9720
Mailing Address - Fax:
Practice Address - Street 1:3098 ARBORSYE CT
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068
Practice Address - Country:US
Practice Address - Phone:614-678-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 138547-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse