Provider Demographics
NPI:1902203367
Name:BOSCH, BRANDON (PMHNP, FNP-BC)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:BOSCH
Suffix:
Gender:M
Credentials:PMHNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:503-764-9042
Practice Address - Street 1:4212 SE DIVISION ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1680
Practice Address - Country:US
Practice Address - Phone:503-963-2575
Practice Address - Fax:503-327-8796
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60801886363LF0000X, 363LP0808X
OR10009817363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily