Provider Demographics
NPI:1912505769
Name:BOSOLUKE, ABIGAIL (PA-C)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:BOSOLUKE
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 1:316 E BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4710
Mailing Address - Country:US
Mailing Address - Phone:406-585-0022
Mailing Address - Fax:406-585-0032
Practice Address - Street 1:316 E BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4710
Practice Address - Country:US
Practice Address - Phone:618-830-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-90444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant