Provider Demographics
NPI:1124477229
Name:BOSMA, MATTHEW ALVIN (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALVIN
Last Name:BOSMA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 S EDGERTON
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301
Mailing Address - Country:US
Mailing Address - Phone:605-996-4778
Mailing Address - Fax:605-996-3660
Practice Address - Street 1:910 S EDGERTON
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301
Practice Address - Country:US
Practice Address - Phone:605-996-4778
Practice Address - Fax:605-996-3660
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1903225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist