Provider Demographics
NPI:1205149838
Name:BOEHME, CANDACE B (PAC)
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:B
Last Name:BOEHME
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 COMANCHE TRL
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:TX
Mailing Address - Zip Code:75094-3612
Mailing Address - Country:US
Mailing Address - Phone:972-825-3241
Mailing Address - Fax:
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-942-5733
Practice Address - Fax:214-942-6115
Is Sole Proprietor?:No
Enumeration Date:2010-07-25
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01020326OtherRAILROAD
TX283341001Medicaid
TXP01020326OtherRAILROAD