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General NPI Number Information
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NPI Number | 1841866183
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Entity Type | Individual
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Provider Name | FREDRICK NYABAYO BOGONKO
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Gender | Male
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Dates
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Enumeration Date | 05/27/2021
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Last Update Date | 05/27/2021
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Provider Practice Location Address
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Address Line | 1601 VINEYARD RD APT 1623
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City | ROSEVILLE
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State | CA
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Zip | 95747-9132
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Country | US
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Telephone | 626-272-6174
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Fax |
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Provider Business Mailing Address
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Address Line | 1601 VINEYARD RD APT 1623
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City | ROSEVILLE
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State | CA
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Zip | 95747-9132
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Country | US
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Telephone | 626-272-6174
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | 812434
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License Number State | CA
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