Basic Information
| Provider Information | |||||||||
| NPI: | 1962483172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSS | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 304 | ||||||||
| Address2: | |||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266620 | ||||||||
| FaxNumber: | 5189261954 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 PARK ST | ||||||||
| Address2: | CR WOOD CANCER CENTER | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189266620 | ||||||||
| FaxNumber: | 5189261954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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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 | 002440 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00007864 | 01 | NY | RR MEDICARE | OTHER | 01280304 | 05 | NY | MEDICAID |