Provider Demographics
NPI:1538448501
Name:ABOAGYE, MICHAEL OTIBU
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:OTIBU
Last Name:ABOAGYE
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 1:77 WAVERLY AVE
Mailing Address - Street 2:APARTMENT 118
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2188
Mailing Address - Country:US
Mailing Address - Phone:646-420-4475
Mailing Address - Fax:
Practice Address - Street 1:33 INDEPENDENCE WAY
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2337
Practice Address - Country:US
Practice Address - Phone:646-420-4475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY649259163W00000X
NY345351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse