Healthcare Provider Details

I. General information

NPI: 1104471986
Provider Name (Legal Business Name): LAUREN BOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN MARIE DESHAW

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 N 120TH AVE STE 20
HOLLAND MI
49424-2196
US

IV. Provider business mailing address

75 KNOLLWOOD PKWY
HOLLAND MI
49423-9284
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-5855
  • Fax: 616-396-5720
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009427
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: