Provider Demographics
NPI:1679587661
Name:BOONSTRA, TODD (PA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:BOONSTRA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 WESTPARK WAY
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-7901
Mailing Address - Country:US
Mailing Address - Phone:616-748-5778
Mailing Address - Fax:
Practice Address - Street 1:8300 WESTPARK WAY
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-7901
Practice Address - Country:US
Practice Address - Phone:616-748-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA759363A00000X
MI5601003342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP42362Medicare UPIN
KY95004768Medicaid