Provider Demographics
NPI:1811656838
Name:BOONSTRA, DANA ELIZABETH
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:ELIZABETH
Last Name:BOONSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2765
Mailing Address - Country:US
Mailing Address - Phone:541-517-6520
Mailing Address - Fax:
Practice Address - Street 1:995 WILLAGILLESPIE RD STE 100
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2186
Practice Address - Country:US
Practice Address - Phone:541-484-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202114248NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty