Basic Information
| Provider Information | |||||||||
| NPI: | 1760475933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOSTROM | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | FL 6 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822713 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2606 HOSPITAL BLVD | ||||||||
| Address2: | 4 WEST | ||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784051833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3619026100 | ||||||||
| FaxNumber: | 3619026935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00623 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA00623 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 345976001 | 05 | TX | MEDICAID | 1L4734 | 01 | TX | MEDICARE | OTHER | P02601724 | 01 | TX | MCRR | OTHER |