Provider Demographics
NPI:1164969812
Name:BOVA, PAUL J JR
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:J
Last Name:BOVA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:J
Other - Last Name:BOVA
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:112 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2919
Mailing Address - Country:US
Mailing Address - Phone:814-688-6678
Mailing Address - Fax:
Practice Address - Street 1:100 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1868
Practice Address - Country:US
Practice Address - Phone:814-368-5648
Practice Address - Fax:814-368-2245
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI001973225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant