Basic Information
| Provider Information | |||||||||
| NPI: | 1457464679 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSWELL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PA/AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19179 W 88TH DR | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800077303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034198732 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DR | ||||||||
| Address2: | STE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 002435 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100000774C | 05 | GA | MEDICAID | 326179 | 01 | GA | WELLCARE | OTHER | 100000774E | 05 | GA | MEDICAID | P00059750 | 01 | GA | RAILROAD MEDICARE | OTHER | N465831 | 01 | GA | WELLCARE | OTHER |