Provider Demographics
NPI:1891283784
Name:BOSHART, ANDREA (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BOSHART
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:BOSHART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:804 N GEORGE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-3459
Mailing Address - Country:US
Mailing Address - Phone:315-368-4229
Mailing Address - Fax:315-368-4229
Practice Address - Street 1:804 N GEORGE ST APT 4
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-3459
Practice Address - Country:US
Practice Address - Phone:315-368-4229
Practice Address - Fax:315-368-4229
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027732-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist