Provider Demographics
NPI:1538278791
Name:BOUMANN, CHRISTINE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:BOUMANN
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 1:6320 WEDGWOOD RD N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3647
Mailing Address - Country:US
Mailing Address - Phone:763-268-0400
Mailing Address - Fax:763-268-0405
Practice Address - Street 1:6320 WEDGWOOD RD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3647
Practice Address - Country:US
Practice Address - Phone:763-268-0400
Practice Address - Fax:763-268-0405
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1318363A00000X
MN9172363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1318OtherPA LICENSE
WI41921500Medicaid
WIS50457Medicare UPIN
WI41921500Medicaid