Provider Demographics
NPI:1992343586
Name:KWAO, RICHARD TEYE (PAC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:TEYE
Last Name:KWAO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WOMACK ARMY MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:724 S HORNER BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4822
Practice Address - Country:US
Practice Address - Phone:919-776-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-15
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT004736363A00000X
NC0010-11512363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant