Provider Demographics
NPI:1093257768
Name:BOSQUE, KRISTOPHER
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:BOSQUE
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 1:21266 VICTORIAS CROSS TER
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4938
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11341 SUNSET HILLS RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5205
Practice Address - Country:US
Practice Address - Phone:703-471-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-13
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001258580163W00000X
VA0024174556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse