Provider Demographics
NPI:1255502019
Name:BOATENG, EDWARD (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:BOATENG
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 SELMA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-2719
Mailing Address - Country:US
Mailing Address - Phone:646-542-9177
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVE
Practice Address - Street 2:MLK-PAVILION, 12 TH FLOOR, SURGERY DEPARTMENT
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010207282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access