Basic Information
| Provider Information | |||||||||
| NPI: | 1477731248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOKU | ||||||||
| FirstName: | ABINET | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18912 HENRY LEE KNOX LN | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280315784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142384181 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271575784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 05/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2009-01476 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2009-01476 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | NC1446 | 05 | SC | MEDICAID | 5918100 | 05 | NC | MEDICAID | 1477731248 | 05 | NC | MEDICAID |