Provider Demographics
NPI:1558313775
Name:BOEHMKE, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:BOEHMKE
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 1:4550 EXECUTIVE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-8805
Mailing Address - Country:US
Mailing Address - Phone:239-566-1226
Mailing Address - Fax:239-566-2519
Practice Address - Street 1:4550 EXECUTIVE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-8805
Practice Address - Country:US
Practice Address - Phone:239-566-1226
Practice Address - Fax:239-566-2519
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0161260-22363L00000X
NC0010-0981363AM0700X
FLPA9108291363A00000X
OH50.002976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2630700Medicaid
NC2630700Medicaid
R18696Medicare UPIN