Provider Demographics
NPI:1093719338
Name:BOMAN, KEITH G (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:BOMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9260 W. SUNSET RD
Mailing Address - Street 2:STE200
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4903
Mailing Address - Country:US
Mailing Address - Phone:702-255-3547
Mailing Address - Fax:702-921-2419
Practice Address - Street 1:601 S RANCHO DR
Practice Address - Street 2:STE. D-28
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4899
Practice Address - Country:US
Practice Address - Phone:702-383-0677
Practice Address - Fax:702-383-0688
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV4089174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002951Medicaid
NVNV 2996OtherBC/BS INDENTIFIER
NVNV 2996OtherBC/BS INDENTIFIER
NVAB9391272OtherDEA NUMBER
NVNV 2996OtherBC/BS INDENTIFIER