Provider Demographics
NPI:1437121043
Name:BOERNER, MARY ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:BOERNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:BOERNER-BARRS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:507 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2000
Mailing Address - Country:US
Mailing Address - Phone:918-567-3128
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:918-567-7044
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK493363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1600493Medicaid
OK1600493Medicaid