Provider Demographics
NPI:1821699943
Name:AKWABOAH, ERNEST
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:AKWABOAH
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 1:87 BURNETT AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3094
Mailing Address - Country:US
Mailing Address - Phone:973-342-6323
Mailing Address - Fax:
Practice Address - Street 1:550 BROAD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4537
Practice Address - Country:US
Practice Address - Phone:201-822-1161
Practice Address - Fax:877-485-8918
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01073500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0763195Medicaid