Provider Demographics
NPI:1154439701
Name:BOSWELL, JONATHAN HALL (PA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:HALL
Last Name:BOSWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5681
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-5681
Mailing Address - Country:US
Mailing Address - Phone:417-831-0150
Mailing Address - Fax:417-831-0155
Practice Address - Street 1:440 E TAMPA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1131
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-831-0155
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005002880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOQ43296Medicare UPIN
MO000097203Medicare ID - Type UnspecifiedMEDICARE