Provider Demographics
NPI:1538565411
Name:BOJANG, IDA
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:BOJANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 MAPLE VALLEY HWY
Mailing Address - Street 2:216
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3955
Mailing Address - Country:US
Mailing Address - Phone:425-463-7625
Mailing Address - Fax:
Practice Address - Street 1:2205 MAPLE VALLEY HWY
Practice Address - Street 2:216
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3955
Practice Address - Country:US
Practice Address - Phone:425-463-7625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60015162164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse