Healthcare Provider Details

I. General information

NPI: 1093769127
Provider Name (Legal Business Name): THOMAS A BOSTAPH CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 FORD AVE
CUMBERLAND MD
21502-4612
US

IV. Provider business mailing address

1602 FORD AVE
CUMBERLAND MD
21502-4612
US

V. Phone/Fax

Practice location:
  • Phone: 301-759-4544
  • Fax: 301-723-4446
Mailing address:
  • Phone: 301-759-4544
  • Fax: 301-723-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR087737
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: