Provider Demographics
NPI:1770239758
Name:EKONG, EKAN J (CNP)
Entity Type:Individual
Prefix:
First Name:EKAN
Middle Name:J
Last Name:EKONG
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 GRASS LAKE PL APT 104
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2048
Mailing Address - Country:US
Mailing Address - Phone:176-349-8444
Mailing Address - Fax:
Practice Address - Street 1:157 GRASS LAKE PL APT 104
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-2048
Practice Address - Country:US
Practice Address - Phone:176-349-8444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9016363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health