Basic Information
| Provider Information | |||||||||
| NPI: | 1104958156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSSHARDT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E CHURCH STREET | ||||||||
| Address2: | MEDICAL STAFF | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934541206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393114 | ||||||||
| FaxNumber: | 8057393502 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 E CHURCH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053463456 | ||||||||
| FaxNumber: | 8053463454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G78405 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G784050 | 05 | CA | MEDICAID |