Basic Information
| Provider Information | |||||||||
| NPI: | 1972597656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOATEN | ||||||||
| FirstName: | AFUA | ||||||||
| MiddleName: | SARPON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1046 RIDGE AVE SW | ||||||||
| Address2: | SOUTHSIDE MEDICAL CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4048013959 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 RIDGE AVE SW | ||||||||
| Address2: | SOUTHSIDE MEDICAL CENTER | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303151640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046881350 | ||||||||
| FaxNumber: | 4048013959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 47166 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54207 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 202I080456 | 01 | GA | MEDICARE PTAN | OTHER | 403610618A,B | 05 | GA | MEDICAID | 403610618 | 05 | GA | MEDICAID |