Provider Demographics
NPI:1609004753
Name:BOESKOOL, ANN MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:MARIE
Last Name:BOESKOOL
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 1:50505 SCHOENHERR RD STE 320
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3141
Mailing Address - Country:US
Mailing Address - Phone:586-580-3062
Mailing Address - Fax:
Practice Address - Street 1:50505 SCHOENHERR RD STE 320
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3141
Practice Address - Country:US
Practice Address - Phone:586-580-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-28
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005522363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1609004753Medicaid