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General NPI Number Information
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NPI Number | 1992936348
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Entity Type | Individual
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Provider Name | CORY MICHAEL JOHANBOEKE PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/03/2009
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Last Update Date | 09/20/2009
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Provider Practice Location Address
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Address Line | 913 N DIXIE AVE
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2503
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Country | US
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Telephone | 270-737-1212
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Fax | 270-706-1141
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Provider Business Mailing Address
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Address Line | 425 S HUBBARDS LN APT 237
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City | LOUISVILLE
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State | KY
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Zip | 40207-4085
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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