Provider Demographics
NPI:1871028167
Name:ABOUA, AMON EUSTACHE
Entity Type:Individual
Prefix:
First Name:AMON
Middle Name:EUSTACHE
Last Name:ABOUA
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 1:411 N MINNESOTA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-2463
Mailing Address - Country:US
Mailing Address - Phone:605-335-0023
Mailing Address - Fax:
Practice Address - Street 1:411 N MINNESOTA AVE STE 101
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-2463
Practice Address - Country:US
Practice Address - Phone:605-335-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD82-0838542Medicaid