Provider Demographics
NPI:1164630265
Name:BOERNER, BRIAN T (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:BOERNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19631 W 97TH ST
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66220-3349
Mailing Address - Country:US
Mailing Address - Phone:913-522-2875
Mailing Address - Fax:
Practice Address - Street 1:11504 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66221-2892
Practice Address - Country:US
Practice Address - Phone:913-681-9909
Practice Address - Fax:913-681-9906
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1103448225100000X
MO2004017077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS29971OtherFREEDOM NETWORK
KS5712220OtherFIRST HEALTH
KS29971OtherTRICARE
KS29971OtherPREFERRED HEALTH PROFESSIONALS
KS7907868OtherAETNA
KS29971025OtherBCBS
KS7907868OtherAETNA