Provider Demographics
NPI:1629067053
Name:BOSWORTH, ABHA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:ABHA
Middle Name:M
Last Name:BOSWORTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8860 CENTER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3068
Mailing Address - Country:US
Mailing Address - Phone:619-460-4055
Mailing Address - Fax:619-460-5148
Practice Address - Street 1:8860 CENTER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3068
Practice Address - Country:US
Practice Address - Phone:619-460-4055
Practice Address - Fax:619-460-5148
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629067053OtherMEDICARE NPI
CA1629067053OtherMEDICARE NPI