Provider Demographics
NPI:1790580108
Name:BOSWORTH, BRIAN J (APRN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:BOSWORTH
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:J
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:46 DIAMOND DR
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-7495
Mailing Address - Country:US
Mailing Address - Phone:804-508-8372
Mailing Address - Fax:
Practice Address - Street 1:46 DIAMOND DR
Practice Address - Street 2:
Practice Address - City:NORTH DINWIDDIE
Practice Address - State:VA
Practice Address - Zip Code:23803-7495
Practice Address - Country:US
Practice Address - Phone:804-508-8372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192634363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty