Provider Demographics
NPI:1285339705
Name:FASAN, BOSEDE RUTH (PTA)
Entity type:Individual
Prefix:
First Name:BOSEDE
Middle Name:RUTH
Last Name:FASAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 GLEN CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-5583
Mailing Address - Country:US
Mailing Address - Phone:973-953-5584
Mailing Address - Fax:
Practice Address - Street 1:1070 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2179
Practice Address - Country:US
Practice Address - Phone:973-953-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004399A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant