Basic Information
| Provider Information | |||||||||
| NPI: | 1184933293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMANKWAAH | ||||||||
| FirstName: | AJOA | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OWUSU | ||||||||
| OtherFirstName: | ADWOA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 728 MARNE HWY STE 100B | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562356600 | ||||||||
| FaxNumber: | 8562356610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB08991000 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0279129 | 05 | NJ | MEDICAID |