Provider Demographics
NPI:1093769127
Name:BOSTAPH, THOMAS A (CRNP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:BOSTAPH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 FORD AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-4612
Mailing Address - Country:US
Mailing Address - Phone:301-759-4544
Mailing Address - Fax:301-723-4446
Practice Address - Street 1:1602 FORD AVE
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-4612
Practice Address - Country:US
Practice Address - Phone:301-759-4544
Practice Address - Fax:301-723-4446
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR087737363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
754LA787OtherMEDICARE
MD342102300Medicaid
754LA787OtherMEDICARE