Basic Information
| Provider Information | |||||||||
| NPI: | 1639219520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOAST | ||||||||
| FirstName: | KAMALA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11720 | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863041720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287715487 | ||||||||
| FaxNumber: | 9287715471 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 WILLOW CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287715487 | ||||||||
| FaxNumber: | 9287715471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 04/27/2011 | ||||||||
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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 | 207P00000X | 223354 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 4600 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2349911 | 05 | NY | MEDICAID |