Provider Demographics
NPI:1457464679
Name:BOSWELL, WILLIAM I IV (PA/AA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:I
Last Name:BOSWELL
Suffix:IV
Gender:M
Credentials:PA/AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002435367H00000X
COANT.0000069367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000774CMedicaid
GA326179OtherWELLCARE
GA100000774EMedicaid
GAP00059750OtherRAILROAD MEDICARE
GAN465831OtherWELLCARE
GA326179OtherWELLCARE
GA100000774CMedicaid
GA32BBBTVMedicare PIN
GA100000774EMedicaid
GA97WCDHZMedicare PIN
R71944Medicare UPIN