Provider Demographics
NPI:1710230172
Name:BOOMER, TIMOTHY LEWIS (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEWIS
Last Name:BOOMER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 71ST ST
Mailing Address - Street 2:SUITE 42
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2394
Mailing Address - Country:US
Mailing Address - Phone:806-799-2991
Mailing Address - Fax:806-793-5331
Practice Address - Street 1:4417 71ST ST
Practice Address - Street 2:SUITE 42
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-2394
Practice Address - Country:US
Practice Address - Phone:806-799-2991
Practice Address - Fax:806-793-5331
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical