Basic Information
| Provider Information | |||||||||
| NPI: | 1033182928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOVE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847854 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003778721 | ||||||||
| FaxNumber: | 3045232241 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 E FLORENCE BLVD | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852225303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203816300 | ||||||||
| FaxNumber: | 5203816618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2850 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 850463 | 05 | AZ | MEDICAID |