Provider Demographics
NPI:1881707156
Name:BOSTOM, BRUCE (PHYSICIANS ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:BOSTOM
Suffix:
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70533
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33307-0533
Mailing Address - Country:US
Mailing Address - Phone:954-267-8777
Mailing Address - Fax:954-772-7801
Practice Address - Street 1:6550 N FEDERAL HWY
Practice Address - Street 2:SUITE 512
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-1404
Practice Address - Country:US
Practice Address - Phone:954-267-8777
Practice Address - Fax:954-772-7801
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS52649Medicare UPIN
FLE0482YMedicare ID - Type Unspecified