Basic Information
| Provider Information | |||||||||
| NPI: | 1417910076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOSEROY | ||||||||
| FirstName: | KANCHANA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31235 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857511235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203242308 | ||||||||
| FaxNumber: | 5203241406 | ||||||||
| Practice Location | |||||||||
| Address1: | 2141 N BEVERLY AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203246290 | ||||||||
| FaxNumber: | 5203246291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 200927 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0006X | 200927 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 56115 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Z214068 | 01 | AZ | MEDICARE | OTHER | 336861 | 05 | AZ | MEDICAID | 02235656 | 05 | NY | MEDICAID |