Provider Demographics
NPI:1861944852
Name:BOESE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BOESE
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 1:1129 MACKINAW LOOP
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:MT
Mailing Address - Zip Code:59932-9789
Mailing Address - Country:US
Mailing Address - Phone:516-320-5937
Mailing Address - Fax:
Practice Address - Street 1:1111 BAKER AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2901
Practice Address - Country:US
Practice Address - Phone:406-862-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical