Provider Demographics
NPI:1508840695
Name:BOATNER, MCKINLEY (PA)
Entity Type:Individual
Prefix:
First Name:MCKINLEY
Middle Name:
Last Name:BOATNER
Suffix:
Gender:M
Credentials:PA
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 30589
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-3589
Mailing Address - Country:US
Mailing Address - Phone:405-769-3301
Mailing Address - Fax:405-769-9685
Practice Address - Street 1:1901 SPRINGLAKE DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-5201
Practice Address - Country:US
Practice Address - Phone:405-521-8486
Practice Address - Fax:405-521-8496
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK578363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK578OtherPA LICENSE
OK200013400AMedicaid
OK200013400BMedicaid
OK200013400CMedicaid
OK578OtherPA LICENSE
371801Medicare PIN