Provider Demographics
NPI:1659873198
Name:BOYTER, KIRRA NIKOLE
Entity Type:Individual
Prefix:
First Name:KIRRA
Middle Name:NIKOLE
Last Name:BOYTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 DRIFTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-5165
Mailing Address - Country:US
Mailing Address - Phone:318-393-1612
Mailing Address - Fax:
Practice Address - Street 1:423 DRIFTWOOD CT
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-5165
Practice Address - Country:US
Practice Address - Phone:318-393-1612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant