Provider Demographics
NPI:1053523480
Name:BOETCHER, KATHLEEN TOMCZYK (PA)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:TOMCZYK
Last Name:BOETCHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14300 GALLANT FOX LN
Mailing Address - Street 2:SUITE 118
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14300 GALLANT FOX LN
Practice Address - Street 2:SUITE 118
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4003
Practice Address - Country:US
Practice Address - Phone:301-464-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant