Healthcare Provider Details

I. General information

NPI: 1447629233
Provider Name (Legal Business Name): BRIAN PATRICK BOSWORTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W COLORADO BLVD PAV II SUITE 431
DALLAS TX
75208-2363
US

IV. Provider business mailing address

221 W COLORADO BLVD PAV II SUITE 431
DALLAS TX
75208-2363
US

V. Phone/Fax

Practice location:
  • Phone: 214-947-3684
  • Fax: 214-947-3239
Mailing address:
  • Phone: 214-947-3684
  • Fax: 214-947-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9109049
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10521
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: