Basic Information
| Provider Information | |||||||||
| NPI: | 1114066115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMISSAH | ||||||||
| FirstName: | IMMANUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18900 N TAMIAMI TRL | ||||||||
| Address2: | STE 9 | ||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395671000 | ||||||||
| FaxNumber: | 2395671008 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 N NELLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891105368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028775199 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2006-0432 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 27280 | WV | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 17098 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 53671074 | 05 | CO | MEDICAID |