Provider Demographics
NPI:1760475933
Name:BOOSTROM, WILLIAM C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:C
Last Name:BOOSTROM
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:FL 6
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2713
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:2606 HOSPITAL BLVD
Practice Address - Street 2:4 WEST
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1833
Practice Address - Country:US
Practice Address - Phone:361-902-6100
Practice Address - Fax:361-902-6935
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2021-04-14
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Provider Licenses
StateLicense IDTaxonomies
TXPA00623363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345976001Medicaid
TX1L4734OtherMEDICARE
TXP02601724OtherMCRR