Healthcare Provider Details

I. General information

NPI: 1588627913
Provider Name (Legal Business Name): JOHN W BOOHER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NE 45TH ST SUITE 102
OAKLAND PARK FL
33334-3814
US

IV. Provider business mailing address

1100 NE 45TH ST SUITE 102
OAKLAND PARK FL
33334-3814
US

V. Phone/Fax

Practice location:
  • Phone: 954-629-0250
  • Fax: 866-240-3482
Mailing address:
  • Phone: 954-629-0250
  • Fax: 866-240-3482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102244
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: