Provider Demographics
NPI:1073696274
Name:VAN DEN BOSCH, ANNETTE RENAE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:RENAE
Last Name:VAN DEN BOSCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 PEEKSKILL RD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-4641
Mailing Address - Country:US
Mailing Address - Phone:813-436-0446
Mailing Address - Fax:813-436-0446
Practice Address - Street 1:8002 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1603
Practice Address - Country:US
Practice Address - Phone:813-880-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104669363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical