Provider Demographics
NPI:1093587750
Name:BOEWE, MIRIAM ELSBETH
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:ELSBETH
Last Name:BOEWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370233 E HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-7044
Mailing Address - Country:US
Mailing Address - Phone:918-935-6138
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-502-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical