Provider Demographics
NPI:1922070200
Name:BOSE, SUSAN M (ANP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:BOSE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:LAWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3321 COLORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-6817
Mailing Address - Country:US
Mailing Address - Phone:940-382-7321
Mailing Address - Fax:940-382-5453
Practice Address - Street 1:3321 COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-6817
Practice Address - Country:US
Practice Address - Phone:940-382-7321
Practice Address - Fax:940-382-5453
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX695571363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163223403Medicaid
TX8Y1394OtherBC & BS
TX163223403Medicaid
TX8Y1394OtherBC & BS