Provider Demographics
NPI:1598124000
Name:BOGATKO, AESOOK LEE
Entity Type:Individual
Prefix:
First Name:AESOOK
Middle Name:LEE
Last Name:BOGATKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9830 N 104TH DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-4704
Mailing Address - Country:US
Mailing Address - Phone:601-717-3203
Mailing Address - Fax:
Practice Address - Street 1:9830 N 104TH DR
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-4704
Practice Address - Country:US
Practice Address - Phone:601-717-3203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP050617164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse