Provider Demographics
NPI:1457023699
Name:BOKKU, GAMMACHIS
Entity Type:Individual
Prefix:
First Name:GAMMACHIS
Middle Name:
Last Name:BOKKU
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 1:736 66TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-1611
Mailing Address - Country:US
Mailing Address - Phone:763-587-8890
Mailing Address - Fax:
Practice Address - Street 1:736 66TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-1611
Practice Address - Country:US
Practice Address - Phone:763-587-8890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN87-2951610Medicaid