1134212921 NPI number — GERALD E BOONE PA CERTIFIED PAC

Table of content: GERALD E BOONE PA CERTIFIED PAC (NPI 1134212921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134212921 NPI number — GERALD E BOONE PA CERTIFIED PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONE
Provider First Name:
GERALD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA CERTIFIED PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134212921
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 S ROSELAWN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARTESIA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-746-3616
Provider Business Mailing Address Fax Number:
575-748-2544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 S ROSELAWN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARTESIA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-746-3616
Provider Business Practice Location Address Fax Number:
575-748-2544
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  PA065 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NMEX PA 065 . This is a "NMEX PA 065" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 72094 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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