Provider Demographics
NPI:1942237961
Name:BOONIN, ALAN (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:BOONIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:176 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18708-1121
Practice Address - Country:US
Practice Address - Phone:570-675-0900
Practice Address - Fax:570-674-8912
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021278E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000845875Medicaid
B36840Medicare UPIN
PA000845875Medicaid