Basic Information
| Provider Information | |||||||||
| NPI: | 1891150785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | IGNATIUS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.M.S., PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3260 TILLMAN DR | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BENSALEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190202029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673320321 | ||||||||
| FaxNumber: | 2673320323 | ||||||||
| Practice Location | |||||||||
| Address1: | 1648 HUNTINGDON PIKE | ||||||||
| Address2: | |||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159382749 | ||||||||
| FaxNumber: | 2159383829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2015 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA058052 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103156901-0001 | 05 | PA | MEDICAID |