Basic Information
| Provider Information | |||||||||
| NPI: | 1851795413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DEN BOSCH | ||||||||
| FirstName: | MARCO | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394241449 | ||||||||
| FaxNumber: | 2394241421 | ||||||||
| Practice Location | |||||||||
| Address1: | 2780 CLEVELAND AVE | ||||||||
| Address2: | SUITE 819 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339015817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393433800 | ||||||||
| FaxNumber: | 2393433993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2014 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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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 | PA9108290 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.