Provider Demographics
NPI:1124067590
Name:BOAN, DONITA KI (DO)
Entity type:Individual
Prefix:
First Name:DONITA
Middle Name:KI
Last Name:BOAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DONITA
Other - Middle Name:KI
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-1078
Mailing Address - Fax:417-347-1079
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-1078
Practice Address - Fax:417-347-1079
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013764207L00000X
OK4085207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology