Provider Demographics
NPI:1992782254
Name:BOONSWANG, PRICHA (MD)
Entity type:Individual
Prefix:
First Name:PRICHA
Middle Name:
Last Name:BOONSWANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 GRUVER AVE
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2808
Mailing Address - Country:US
Mailing Address - Phone:610-252-2229
Mailing Address - Fax:610-252-8468
Practice Address - Street 1:2358 GRUVER AVE
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2808
Practice Address - Country:US
Practice Address - Phone:610-252-2229
Practice Address - Fax:610-252-8468
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033757L208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
0050575000OtherKHP EAST
0990471OtherKHP CENRAL
NJ4961200Medicaid
PA0006479210002Medicaid
PA0006479210002Medicaid
NJ4961200Medicaid