Healthcare Provider Details

I. General information

NPI: 1407385149
Provider Name (Legal Business Name): GILBERT AGYEMANG-BOAKYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11711 SAND CANYON RD
YUCAIPA CA
92399-1742
US

IV. Provider business mailing address

25590 PROSPECT AVE APT 42F
LOMA LINDA CA
92354-3155
US

V. Phone/Fax

Practice location:
  • Phone: 909-389-3272
  • Fax:
Mailing address:
  • Phone: 951-534-7114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: