Provider Demographics
NPI:1942270723
Name:BOENICKE, BRANDAN CONICE (PA)
Entity Type:Individual
Prefix:
First Name:BRANDAN
Middle Name:CONICE
Last Name:BOENICKE
Suffix:
Gender:M
Credentials:PA
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 437
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78292-0437
Mailing Address - Country:US
Mailing Address - Phone:210-558-6288
Mailing Address - Fax:210-558-6289
Practice Address - Street 1:1801 N BEDELL AVE
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-8001
Practice Address - Country:US
Practice Address - Phone:830-768-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS54171Medicare UPIN