Provider Demographics
NPI:1295069664
Name:BOOSE, MEGAN JEAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:JEAN
Last Name:BOOSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3173 43RD ST S STE A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4564
Mailing Address - Country:US
Mailing Address - Phone:701-478-8780
Mailing Address - Fax:701-478-8781
Practice Address - Street 1:3173 43RD ST S STE A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4564
Practice Address - Country:US
Practice Address - Phone:701-478-8780
Practice Address - Fax:701-478-8781
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2020-08-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00226200363A00000X
NDPAC0844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant