Provider Demographics
NPI:1467699959
Name:BOSANEK, THERESA E (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:BOSANEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 FANNIN ST STE 2070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1541
Mailing Address - Country:US
Mailing Address - Phone:713-704-6731
Mailing Address - Fax:713-704-6889
Practice Address - Street 1:6400 FANNIN ST STE 2800
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1534
Practice Address - Country:US
Practice Address - Phone:713-704-7100
Practice Address - Fax:713-704-1262
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362899201Medicaid
TX8964MAOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8964MAOtherBLUE CROSS BLUE SHIELD OF TEXAS