1679314520 NPI number — MARKUS BOSLEY PSS, PAS-DOT, LAC

Table of content: MARKUS BOSLEY PSS, PAS-DOT, LAC (NPI 1679314520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679314520 NPI number — MARKUS BOSLEY PSS, PAS-DOT, LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSLEY
Provider First Name:
MARKUS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSS, PAS-DOT, LAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679314520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1108 STUBBS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-5620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-791-9805
Provider Business Mailing Address Fax Number:
318-855-4396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-6532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-791-9805
Provider Business Practice Location Address Fax Number:
318-855-4396
Provider Enumeration Date:
06/04/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  LAC-5143 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com