Provider Demographics
NPI:1538160403
Name:BOOGAART, DAMON M (DNP, CFNP)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:M
Last Name:BOOGAART
Suffix:
Gender:M
Credentials:DNP, CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9607
Mailing Address - Country:US
Mailing Address - Phone:440-943-2500
Mailing Address - Fax:440-516-8345
Practice Address - Street 1:2570 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9607
Practice Address - Country:US
Practice Address - Phone:440-943-2500
Practice Address - Fax:440-516-8345
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000544A363LF0000X
OHNP 08627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000297161OtherBC/BS #
IN100321450Medicaid
OH2288117Medicaid
INS84662Medicare UPIN
OH2288117Medicaid