Provider Demographics
NPI:1568089043
Name:BOERNER, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BOERNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6565 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43016-8461
Practice Address - Country:US
Practice Address - Phone:740-304-0151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH409226163WG0000X
OH0027182363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRNCNP0027182OtherLICENSE