Provider Demographics
NPI:1649766494
Name:BOSCO, HEATHER LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:BOSCO
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 1:150 E 42ND ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-5699
Mailing Address - Country:US
Mailing Address - Phone:646-605-8186
Mailing Address - Fax:
Practice Address - Street 1:10 E 102ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6030
Practice Address - Country:US
Practice Address - Phone:212-241-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008734363A00000X
NY023432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant