Provider Demographics
NPI:1851795413
Name:VAN DEN BOSCH, MARCO (PA)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:VAN DEN BOSCH
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:2780 CLEVELAND AVE
Practice Address - Street 2:SUITE 819
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5817
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant