Provider Demographics
NPI:1013679273
Name:ETANG, AYUK B
Entity Type:Individual
Prefix:
First Name:AYUK
Middle Name:B
Last Name:ETANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PARK LN S APT 5
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1922
Mailing Address - Country:US
Mailing Address - Phone:518-250-8685
Mailing Address - Fax:
Practice Address - Street 1:1205 TROY SCHENECTADY RD STE 100
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1075
Practice Address - Country:US
Practice Address - Phone:518-348-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347994-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner