Basic Information
| Provider Information | |||||||||
| NPI: | 1265861058 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOZEMAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1512 W KIRBY PL | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2013 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.200677 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 329917YH54 | 01 | LA | MEDICARE - PTAN | OTHER | 2348221 | 05 | LA | MEDICAID |