Provider Demographics
NPI:1548890304
Name:AGYEMANG, ENOCH
Entity type:Individual
Prefix:
First Name:ENOCH
Middle Name:
Last Name:AGYEMANG
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 1:146 SHORT BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-4642
Mailing Address - Country:US
Mailing Address - Phone:678-651-9336
Mailing Address - Fax:
Practice Address - Street 1:146 SHORT BRANCH RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-4642
Practice Address - Country:US
Practice Address - Phone:678-651-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA673299991207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services