Provider Demographics
NPI:1922462225
Name:BOERNER, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BOERNER
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 1:9909 E PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2777 E CAMELBACK RD STE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4351
Practice Address - Country:US
Practice Address - Phone:480-946-7939
Practice Address - Fax:480-946-5258
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant