Provider Demographics
NPI:1326637505
Name:BOEKER, SHANE KYLE
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:KYLE
Last Name:BOEKER
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 1:7608 WATSON ST # B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-1538
Mailing Address - Country:US
Mailing Address - Phone:512-649-6989
Mailing Address - Fax:
Practice Address - Street 1:1801 E 51ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3434
Practice Address - Country:US
Practice Address - Phone:512-474-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30035567183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician