Provider Demographics
NPI:1033520192
Name:DEBOER, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DEBOER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6980 MOUNTAIN MOSS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-3815
Mailing Address - Country:US
Mailing Address - Phone:702-222-4307
Mailing Address - Fax:
Practice Address - Street 1:3269 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3619
Practice Address - Country:US
Practice Address - Phone:702-222-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ007293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program