Provider Demographics
NPI:1528465937
Name:BOOTHE, LAUREN ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:BOOTHE
Suffix:
Gender:F
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 1:315 TURWILL LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-4231
Mailing Address - Country:US
Mailing Address - Phone:269-343-8170
Mailing Address - Fax:269-382-8490
Practice Address - Street 1:315 TURWILL LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-4231
Practice Address - Country:US
Practice Address - Phone:269-343-8170
Practice Address - Fax:269-382-8490
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005325363A00000X
MI5601007226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1528465937Medicaid