Provider Demographics
NPI:1427698307
Name:BARASA, BOAZ NYONGESA
Entity type:Individual
Prefix:
First Name:BOAZ
Middle Name:NYONGESA
Last Name:BARASA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2604
Mailing Address - Country:US
Mailing Address - Phone:574-575-8824
Mailing Address - Fax:
Practice Address - Street 1:17475 DUGDALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1545
Practice Address - Country:US
Practice Address - Phone:574-247-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005605A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0OtherN/A