Provider Demographics
NPI:1720190127
Name:BOHN, KERILYN KRAKE (PA-C)
Entity Type:Individual
Prefix:
First Name:KERILYN
Middle Name:KRAKE
Last Name:BOHN
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 1:1607 RUBBLE RD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-4383
Mailing Address - Country:US
Mailing Address - Phone:319-230-8375
Mailing Address - Fax:
Practice Address - Street 1:1607 RUBBLE RD
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-4383
Practice Address - Country:US
Practice Address - Phone:319-230-8375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101709363AM0700X
FL9101709363AM0700X
IA098740363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001536600Medicaid
FLCR325ZMedicare PIN