Provider Demographics
NPI:1013167162
Name:BOOMHOWER, MEGHAN T (PA - C)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:T
Last Name:BOOMHOWER
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 1:19815 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2505
Mailing Address - Country:US
Mailing Address - Phone:313-880-1220
Mailing Address - Fax:
Practice Address - Street 1:19815 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-2505
Practice Address - Country:US
Practice Address - Phone:313-880-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant