Provider Demographics
NPI:1154852705
Name:BOONIPAT, THANAPOOM
Entity Type:Individual
Prefix:MR
First Name:THANAPOOM
Middle Name:
Last Name:BOONIPAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 22ND ST STE E
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1156
Mailing Address - Country:US
Mailing Address - Phone:603-731-6888
Mailing Address - Fax:
Practice Address - Street 1:3813 22ND ST STE E
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1156
Practice Address - Country:US
Practice Address - Phone:603-731-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN64276208200000X
MN28451208200000X
TXU9214208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery