Healthcare Provider Details

I. General information

NPI: 1013009976
Provider Name (Legal Business Name): BRIGHT BOAFO NKRUMAH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-1114
  • Fax: 845-333-1102
Mailing address:
  • Phone: 845-333-1114
  • Fax: 845-333-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006344
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006344
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: