Provider Demographics
NPI:1134366081
Name:BOSSUAH, KWAGHDOO ATSOR (NP)
Entity type:Individual
Prefix:
First Name:KWAGHDOO
Middle Name:ATSOR
Last Name:BOSSUAH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 E MAIN ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-2144
Mailing Address - Country:US
Mailing Address - Phone:888-289-5959
Mailing Address - Fax:
Practice Address - Street 1:131 E MAIN ST UNIT 1
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-2144
Practice Address - Country:US
Practice Address - Phone:888-289-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211774363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
0M74460262Medicare PIN