Provider Demographics
NPI:1790722171
Name:NORONHA, BOSCO EDRIC (MD)
Entity Type:Individual
Prefix:
First Name:BOSCO
Middle Name:EDRIC
Last Name:NORONHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 WAYNE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3578
Mailing Address - Country:US
Mailing Address - Phone:724-349-5440
Mailing Address - Fax:724-349-7445
Practice Address - Street 1:1265 WAYNE AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3578
Practice Address - Country:US
Practice Address - Phone:724-349-5440
Practice Address - Fax:724-349-7445
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD072191L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001836979Medicaid
PA001836979Medicaid
PA046437Medicare ID - Type Unspecified