Provider Demographics
NPI:1801815550
Name:BOSCH, DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BOSCH
Suffix:
Gender:M
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 1:920 DOUG WHITE DR STE 510
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4120
Mailing Address - Country:US
Mailing Address - Phone:843-497-7772
Mailing Address - Fax:843-848-7530
Practice Address - Street 1:920 DOUG WHITE DR STE 510
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4120
Practice Address - Country:US
Practice Address - Phone:843-497-7772
Practice Address - Fax:843-848-7530
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2243363A00000X
MO2020004735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2062PAMedicaid
SC2062PAMedicaid
SCSC50289169Medicare PIN