Provider Demographics
NPI:1841866183
Name:BOGONKO, FREDRICK NYABAYO
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:NYABAYO
Last Name:BOGONKO
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 1:1601 VINEYARD RD APT 1623
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9132
Mailing Address - Country:US
Mailing Address - Phone:626-272-6174
Mailing Address - Fax:
Practice Address - Street 1:1601 VINEYARD RD APT 1623
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-9132
Practice Address - Country:US
Practice Address - Phone:626-272-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA812434163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty