Provider Demographics
NPI:1801412606
Name:BOENSCH, TREVOR FRANCIS (CAA)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:FRANCIS
Last Name:BOENSCH
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 N NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3926
Mailing Address - Country:US
Mailing Address - Phone:708-491-7421
Mailing Address - Fax:
Practice Address - Street 1:202 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1507
Practice Address - Country:US
Practice Address - Phone:608-267-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI166-17367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant