Provider Demographics
NPI:1497272215
Name:BOEHM, ERIC ROSS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ROSS
Last Name:BOEHM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SUN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53018-2318
Mailing Address - Country:US
Mailing Address - Phone:262-928-4043
Mailing Address - Fax:
Practice Address - Street 1:2301 SUN VALLEY DR
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-2318
Practice Address - Country:US
Practice Address - Phone:262-928-4043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4166-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant