Provider Demographics
NPI:1871908335
Name:BOSSOLINI, MARYBETH
Entity type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:BOSSOLINI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:101 JORDAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-8309
Practice Address - Country:US
Practice Address - Phone:518-274-0476
Practice Address - Fax:518-274-0497
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400283099Medicare PIN