Provider Demographics
NPI:1407401607
Name:BOELENS, BLAKE WILLIAM (PA-S)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:WILLIAM
Last Name:BOELENS
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 MORIN DR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-7785
Mailing Address - Country:US
Mailing Address - Phone:940-600-0398
Mailing Address - Fax:
Practice Address - Street 1:11500 STATE HIGHWAY 121 STE 510
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-9348
Practice Address - Country:US
Practice Address - Phone:469-200-4093
Practice Address - Fax:469-200-4079
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA14195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program