Provider Demographics
NPI:1538133558
Name:BOAN, KRISTY RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:RAE
Last Name:BOAN
Suffix:
Gender:F
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:PO BOX 8500
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8500
Mailing Address - Country:US
Mailing Address - Phone:910-715-1010
Mailing Address - Fax:910-715-1026
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2164
Practice Address - Fax:910-715-1926
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02678208M00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506041Medicaid
NV100506041Medicaid
Q44193Medicare UPIN