Provider Demographics
NPI:1710051255
Name:BOOG, GARY L (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:BOOG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:L
Other - Last Name:BOOG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:915 ANDERSON DR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-1006
Mailing Address - Country:US
Mailing Address - Phone:360-532-8830
Mailing Address - Fax:
Practice Address - Street 1:915 ANDERSON DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1006
Practice Address - Country:US
Practice Address - Phone:360-532-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60037894363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM343725001Medicare PIN