Provider Demographics
NPI:1790732097
Name:BOEHM, IVEN W (PA-C)
Entity Type:Individual
Prefix:
First Name:IVEN
Middle Name:W
Last Name:BOEHM
Suffix:
Gender:M
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:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-0372
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:
Practice Address - Street 1:650 OAK AVE
Practice Address - Street 2:
Practice Address - City:NEOGA
Practice Address - State:IL
Practice Address - Zip Code:62447-1502
Practice Address - Country:US
Practice Address - Phone:217-895-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant