Basic Information
| Provider Information | |||||||||
| NPI: | 1649682303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYACK | ||||||||
| FirstName: | DANE | ||||||||
| MiddleName: | CLIFTON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9100 W 74TH ST | ||||||||
| Address2: | |||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662044004 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9100 W 74TH ST | ||||||||
| Address2: | |||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136762214 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2014 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10049910 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.