Healthcare Provider Details

I. General information

NPI: 1174073886
Provider Name (Legal Business Name): ALICIA A AFRAH-BOATENG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 GROSSMONT CENTER DR
LA MESA CA
91942-3009
US

IV. Provider business mailing address

5525 GROSSMONT CENTER DR
LA MESA CA
91942-3009
US

V. Phone/Fax

Practice location:
  • Phone: 319-631-8652
  • Fax:
Mailing address:
  • Phone: 619-800-4179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59844
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: