Provider Demographics
NPI:1003525841
Name:BOSS, DESARAE (PA-C)
Entity Type:Individual
Prefix:
First Name:DESARAE
Middle Name:
Last Name:BOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 VISTA COURT DR APT 4304
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-0096
Mailing Address - Country:US
Mailing Address - Phone:283-034-2899
Mailing Address - Fax:
Practice Address - Street 1:7515 GREENVILLE AVE STE 900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3851
Practice Address - Country:US
Practice Address - Phone:844-585-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical