Provider Demographics
NPI:1053022814
Name:BOAKYE, IRENE (PA-C)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BOAKYE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W 111TH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-4072
Mailing Address - Country:US
Mailing Address - Phone:347-569-7239
Mailing Address - Fax:
Practice Address - Street 1:3424 KOSSUTH AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2410
Practice Address - Country:US
Practice Address - Phone:718-519-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
029293OtherPHYSICIAN ASSISTANT LICENSE
NYTX52501UMedicaid