Provider Demographics
NPI:1538910732
Name:AYOMBISA, DOUGLAS AKANKPAB-BOKA
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:AKANKPAB-BOKA
Last Name:AYOMBISA
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 1:16 VOORHEESVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:VOORHEESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12186-9724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16 VOORHEESVILLE AVE
Practice Address - Street 2:
Practice Address - City:VOORHEESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12186-9724
Practice Address - Country:US
Practice Address - Phone:518-590-5386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY702856163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency