Provider Demographics
NPI:1013090018
Name:BOEHM, LAURIE K (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:K
Last Name:BOEHM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 JENKS AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4304
Mailing Address - Country:US
Mailing Address - Phone:850-215-6008
Mailing Address - Fax:850-215-6020
Practice Address - Street 1:2428 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4304
Practice Address - Country:US
Practice Address - Phone:850-215-6008
Practice Address - Fax:850-215-6020
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103644363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292612100Medicaid
FL292612100Medicaid