Provider Demographics
NPI:1457346959
Name:BOERNER, KEVIN M (PAC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:BOERNER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 CELEBRATION PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5432
Mailing Address - Country:US
Mailing Address - Phone:407-303-4673
Mailing Address - Fax:855-834-5435
Practice Address - Street 1:410 CELEBRATION PLACE
Practice Address - Street 2:SUITE 200
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5432
Practice Address - Country:US
Practice Address - Phone:407-303-4673
Practice Address - Fax:407-398-0050
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1628363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290145500Medicaid
FL290145500Medicaid
FLE3713Medicare PIN