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NPI Code Detail

MEDICARE: AMY JEAN BOONE PA-C

MEDICARE: AMY JEAN 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
1363A00000XPhysician Assistant5601003186MI

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2M74460743OTHERMIMEDICARE PTAN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
108-5-70-1100-0OTHERMIBCBS

General Provider Information

NPI Number : 1881694479
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMY JEAN BOONE PA-C
Provider Business Mailing Address
First Line : 100 MICHIGAN ST NE
Second Line : MC 845
City : GRAND RAPIDS
State : MI
Zip : 49503-2560
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3152 PORT SHELDON ST
Second Line : SUITE C
City : HUDSONVILLE
State : MI
Zip : 49426-9297
Country : US
Telephone Number : 616-669-9238
Fax Number : 616-669-8296
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2005
Last Update Date : 02/26/2021

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Directions to “ AMY JEAN BOONE PA-C” Practice Location

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