Basic Information
| Provider Information | |||||||||
| NPI: | 1275736514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSCO | ||||||||
| FirstName: | MAUREEN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Practice Location | |||||||||
| Address1: | 1874 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723377676 | ||||||||
| FaxNumber: | 7723379034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 06/07/2011 | ||||||||
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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 | 367500000X | ARNP606762 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 311312400 | 05 | FL | MEDICAID | G2588 | 01 | BCBS | OTHER |