Provider Demographics
NPI:1891152146
Name:VANDEN BOSCH, SCOTT RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RUSSELL
Last Name:VANDEN 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 1:121 HATCH AVE
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-1242
Mailing Address - Country:US
Mailing Address - Phone:616-644-4821
Mailing Address - Fax:
Practice Address - Street 1:121 HATCH AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1242
Practice Address - Country:US
Practice Address - Phone:616-644-4821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant