Provider Demographics
NPI:1346519972
Name:BOSTWICK, BEAU J
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:J
Last Name:BOSTWICK
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:USS DEFENDER
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96663-1922
Mailing Address - Country:US
Mailing Address - Phone:0802-738-2390
Mailing Address - Fax:
Practice Address - Street 1:USS DEFENDER
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96663-1922
Practice Address - Country:US
Practice Address - Phone:0802-738-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman