MEDICARE: MR. SHAKESPEAR BOKA RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	592166	NY

General Provider Information

NPI Number	:	1801058284
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHAKESPEAR BOKA RN

Provider Business Mailing Address
First Line	:	14311 LAKEWOOD AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11435-5407
Country	:	US
Telephone Number	:	718-657-2325
Fax Number	:

Provider Business Practice Location Address
First Line	:	14311 LAKEWOOD AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11435-5407
Country	:	US
Telephone Number	:	718-657-2325
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	06/27/2008

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