Provider Demographics
NPI:1164617122
Name:BOOMERSHINE, MARK A (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:BOOMERSHINE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3496 E LAKE LANSING RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2288
Mailing Address - Country:US
Mailing Address - Phone:517-333-0968
Mailing Address - Fax:517-333-4306
Practice Address - Street 1:3496 E LAKE LANSING RD
Practice Address - Street 2:SUITE 100
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2288
Practice Address - Country:US
Practice Address - Phone:517-333-0968
Practice Address - Fax:517-333-4306
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB1081378OtherDEA