MEDICARE: KEVIN M BOERNER PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA1628	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457346959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN M BOERNER PAC

Provider Business Mailing Address
First Line	:	410 CELEBRATION PLACE
Second Line	:	SUITE 200
City	:	CELEBRATION
State	:	FL
Zip	:	34747-5432
Country	:	US
Telephone Number	:	407-303-4673
Fax Number	:	855-834-5435

Provider Business Practice Location Address
First Line	:	410 CELEBRATION PLACE
Second Line	:	SUITE 200
City	:	CELEBRATION
State	:	FL
Zip	:	34747-5432
Country	:	US
Telephone Number	:	407-303-4673
Fax Number	:	407-398-0050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	01/14/2014

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Directions to “ KEVIN M BOERNER PAC” Practice Location

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