Healthcare Provider Details

I. General information

NPI: 1306193248
Provider Name (Legal Business Name): JACOB DANIEL BOYER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2012
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 4TH AVE
GRINNELL IA
50112-1898
US

IV. Provider business mailing address

210 4TH AVE
GRINNELL IA
50112-1898
US

V. Phone/Fax

Practice location:
  • Phone: 641-236-2500
  • Fax:
Mailing address:
  • Phone: 641-236-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002319
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: