Provider Demographics
NPI:1790162527
Name:BOATENG, SAMUEL (CRNP)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:BOATENG
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:301-758-2350
Mailing Address - Fax:
Practice Address - Street 1:999 DALTON AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-2903
Practice Address - Country:US
Practice Address - Phone:413-448-6231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDF0415163363L00000X
MARN2316205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1790162527Medicaid