Provider Demographics
NPI:1619681087
Name:BOSKE, AMANDA ROSE (MEDI-CAL PSS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:BOSKE
Suffix:
Gender:F
Credentials:MEDI-CAL PSS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ROSE
Other - Last Name:KAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 N PALM CANYON DR STE A4
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-1866
Mailing Address - Country:US
Mailing Address - Phone:760-424-5602
Mailing Address - Fax:760-670-2734
Practice Address - Street 1:2500 N PALM CANYON DR STE A4
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-1866
Practice Address - Country:US
Practice Address - Phone:760-424-5602
Practice Address - Fax:760-670-2734
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-OVETLI175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist