Healthcare Provider Details

I. General information

NPI: 1649250713
Provider Name (Legal Business Name): NATHAN EARL BOONSTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 PLEASANT ST SUITE 300
DES MOINES IA
50309-1453
US

IV. Provider business mailing address

1212 PLEASANT ST SUITE 300
DES MOINES IA
50309-1453
US

V. Phone/Fax

Practice location:
  • Phone: 515-241-8923
  • Fax: 515-241-8728
Mailing address:
  • Phone: 515-241-8923
  • Fax: 515-241-8728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36377
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: