Provider Demographics
NPI:1952178295
Name:BOONE, NATHANAEL KENTON (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:KENTON
Last Name:BOONE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2087 ACORN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-7306
Mailing Address - Country:US
Mailing Address - Phone:317-738-8095
Mailing Address - Fax:
Practice Address - Street 1:2087 ACORN BLVD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-7306
Practice Address - Country:US
Practice Address - Phone:317-738-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004369A363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program