Healthcare Provider Details

I. General information

NPI: 1104377282
Provider Name (Legal Business Name): HEATHER BOSTANCIC CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BOULEVARD SUITE 9329
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

100 EAST PENN SQUARE THE WANAMAKER BLDG., 9TH FL. N
PHILADELPHIA PA
19107-3323
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1858
  • Fax: 215-590-1415
Mailing address:
  • Phone: 267-425-9300
  • Fax: 267-425-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN606709
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: