Healthcare Provider Details

I. General information

NPI: 1700885308
Provider Name (Legal Business Name): GERALD BOSSERT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 09/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST SUITE D
PAYSON AZ
85541-5488
US

IV. Provider business mailing address

126 E MAIN ST SUITE D
PAYSON AZ
85541-5488
US

V. Phone/Fax

Practice location:
  • Phone: 928-472-5260
  • Fax:
Mailing address:
  • Phone: 928-472-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1897
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1897
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: