Healthcare Provider Details

I. General information

NPI: 1992314439
Provider Name (Legal Business Name): PHILIP BOADU NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4763 ATLANTA HWY STE 420
LOGANVILLE GA
30052-6788
US

IV. Provider business mailing address

452 SPRINGLAKE RD
LAWRENCEVILLE GA
30046-5090
US

V. Phone/Fax

Practice location:
  • Phone: 404-395-6781
  • Fax:
Mailing address:
  • Phone: 646-226-7209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number651299
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP303104
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF346860-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: