Provider Demographics
NPI:1205258399
Name:AGYEMAN, KWABENA BOAKYE (CRNA)
Entity type:Individual
Prefix:
First Name:KWABENA
Middle Name:BOAKYE
Last Name:AGYEMAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-7296
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-341-7296
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041390031163W00000X
MO2011001948163W00000X
KY1139036163W00000X
KY3008561367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse