Provider Demographics
NPI:1063517100
Name:BOADU, SAMUEL YAW (DNP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:YAW
Last Name:BOADU
Suffix:
Gender:M
Credentials:DNP
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Other - Credentials:
Mailing Address - Street 1:409 NORTH DUNLAP STREET
Mailing Address - Street 2:OPEN CITIES HEALTH CENTER
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4201
Mailing Address - Country:US
Mailing Address - Phone:651-290-9200
Mailing Address - Fax:651-290-9210
Practice Address - Street 1:409 NORTH DUNLAP STREET
Practice Address - Street 2:OPEN CITIES HEALTH CENTER
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4201
Practice Address - Country:US
Practice Address - Phone:651-290-9200
Practice Address - Fax:651-290-9210
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-01-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR 153044-3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500003510Medicare UPIN