Basic Information
| Provider Information | |||||||||
| NPI: | 1649250713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOONSTRA | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | EARL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1212 PLEASANT ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152418923 | ||||||||
| FaxNumber: | 5152418728 | ||||||||
| Practice Location | |||||||||
| Address1: | 1212 PLEASANT ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152418923 | ||||||||
| FaxNumber: | 5152418728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 11/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 36377 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 207559006 | 05 | MO | MEDICAID | 1649250713 | 05 | IA | MEDICAID | 17515008 | 01 | MEDICARE | OTHER |