Provider Demographics
NPI:1881694479
Name:BOONE, AMY JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3152 PORT SHELDON ST
Practice Address - Street 2:SUITE C
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9297
Practice Address - Country:US
Practice Address - Phone:616-669-9238
Practice Address - Fax:616-669-8296
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08-5-70-1100-0OtherBCBS
MIM74460743OtherMEDICARE PTAN
MI08-5-70-1100-0OtherBCBS