MEDICARE: ANTHONY D BOSLEY SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver		WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7638156	OTHER		PROVIDER

General Provider Information

NPI Number	:	1669008280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY D BOSLEY SR.

Provider Business Mailing Address
First Line	:	2721 N WHIPPLE CT
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-4708
Country	:	US
Telephone Number	:	509-608-2380
Fax Number	:	509-267-0071

Provider Business Practice Location Address
First Line	:	2721 N WHIPPLE CT
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99206-4708
Country	:	US
Telephone Number	:	509-608-2380
Fax Number	:	509-267-0071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2020
Last Update Date	:	03/15/2020

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