Provider Demographics
NPI:1629502257
Name:BOATENG, COLLINS KWABENA (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLINS
Middle Name:KWABENA
Last Name:BOATENG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 OLD BRIDGE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKERIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2945
Mailing Address - Country:US
Mailing Address - Phone:703-499-8787
Mailing Address - Fax:703-499-8222
Practice Address - Street 1:2070 OLD BRIDGE RD STE 103
Practice Address - Street 2:
Practice Address - City:LAKERIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2945
Practice Address - Country:US
Practice Address - Phone:703-499-8787
Practice Address - Fax:703-499-8222
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005729363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical