Healthcare Provider Details

I. General information

NPI: 1861944852
Provider Name (Legal Business Name): SHANNON BOESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 BAKER AVE
WHITEFISH MT
59937-2901
US

IV. Provider business mailing address

1129 MACKINAW LOOP
SOMERS MT
59932-9789
US

V. Phone/Fax

Practice location:
  • Phone: 406-862-2515
  • Fax:
Mailing address:
  • Phone: 516-320-5937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: