Provider Demographics
NPI:1093171704
Name:BOEN, MAKENZIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
Last Name:BOEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 SOUTHWEST BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-6915
Mailing Address - Country:US
Mailing Address - Phone:817-731-9198
Mailing Address - Fax:817-731-9199
Practice Address - Street 1:2520 W UNIVERSITY DR STE 1154
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-1616
Practice Address - Country:US
Practice Address - Phone:940-220-5901
Practice Address - Fax:940-566-1715
Is Sole Proprietor?:No
Enumeration Date:2016-01-11
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2587363A00000X
TXPA11260363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK52117OtherOBNDD