=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215516794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEAGHAN LYNN BOEKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2021
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8915 W CONNELL AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-3067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-266-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5742 ASPEN CT
-----------------------------------------------------
City | DENMARK
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54208-9491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-784-6586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 756843
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------