Provider Demographics
NPI:1447430459
Name:BOATENG, EMMANUEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:BOATENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 CONCOURSE VLG E
Mailing Address - Street 2:APT 1G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3903
Mailing Address - Country:US
Mailing Address - Phone:646-642-4338
Mailing Address - Fax:
Practice Address - Street 1:773 CONCOURSE VLG E
Practice Address - Street 2:APT 1G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3903
Practice Address - Country:US
Practice Address - Phone:646-642-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5621842164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02843649Medicaid