Provider Demographics
NPI:1427399476
Name:BOERE, MARIANKA ALEXANDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIANKA
Middle Name:ALEXANDRA
Last Name:BOERE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-965-7733
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-3884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4374367500000X
CANA4374367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA170787Medicare PIN