Provider Demographics
NPI:1073287355
Name:BOSWELL, SCOTT G
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:G
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 WEATHERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-1987
Mailing Address - Country:US
Mailing Address - Phone:714-404-6330
Mailing Address - Fax:
Practice Address - Street 1:1611 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3593
Practice Address - Country:US
Practice Address - Phone:678-391-4373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA004705225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant