Provider Demographics
NPI:1295117364
Name:BOO, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 E PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-2142
Mailing Address - Country:US
Mailing Address - Phone:785-202-1592
Mailing Address - Fax:
Practice Address - Street 1:1575 N 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2091
Practice Address - Country:US
Practice Address - Phone:307-745-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1105049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist