Provider Demographics
NPI:1992936348
Name:JOHANBOEKE, CORY MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:MICHAEL
Last Name:JOHANBOEKE
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:425 S HUBBARDS LN APT 237
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4085
Mailing Address - Country:US
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Practice Address - Street 1:913 N DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2503
Practice Address - Country:US
Practice Address - Phone:270-737-1212
Practice Address - Fax:270-706-1141
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-09-20
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant