Provider Demographics
NPI:1104464460
Name:DAVID N AMPONG
Entity type:Organization
Organization Name:DAVID N AMPONG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-712-2662
Mailing Address - Street 1:1577 C ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-5164
Mailing Address - Country:US
Mailing Address - Phone:907-538-9958
Mailing Address - Fax:907-865-2433
Practice Address - Street 1:1577 C ST STE 201
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-5164
Practice Address - Country:US
Practice Address - Phone:907-538-9958
Practice Address - Fax:907-865-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-18
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1701389Medicaid