MEDICARE: CARLY JAY BOONE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA05842	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA05842	OTHER	TX	PHYSCICIAN ASSISTANT LICENSE
2	1082631	OTHER	TX	CERTIFIED PAC

General Provider Information

NPI Number	:	1801052030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY JAY BOONE PA-C

Provider Business Mailing Address
First Line	:	2460 N IH 35 E STE 100
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5267
Country	:	US
Telephone Number	:	469-800-9500
Fax Number	:	469-800-9540

Provider Business Practice Location Address
First Line	:	2460 N IH 35 E STE 100
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-5267
Country	:	US
Telephone Number	:	469-800-9500
Fax Number	:	469-800-9540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2008
Last Update Date	:	02/19/2024

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Directions to “ CARLY JAY BOONE PA-C” Practice Location

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