Provider Demographics
NPI:1184916801
Name:KWABENA AMPONSAH PA-C, PLLC
Entity type:Organization
Organization Name:KWABENA AMPONSAH PA-C, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KWABENA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMPONSAH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:937-902-2068
Mailing Address - Street 1:10524 MOSS PARK RD STE 204-771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-5898
Mailing Address - Country:US
Mailing Address - Phone:937-902-2068
Mailing Address - Fax:
Practice Address - Street 1:10524 MOSS PARK RD STE 204-771
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-5898
Practice Address - Country:US
Practice Address - Phone:937-902-2068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99974208D00000X
FLPA9104033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty