Provider Demographics
NPI:1962283622
Name:AMOSUN, BOSE
Entity type:Individual
Prefix:
First Name:BOSE
Middle Name:
Last Name:AMOSUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 4TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-7053
Mailing Address - Country:US
Mailing Address - Phone:253-848-5951
Mailing Address - Fax:
Practice Address - Street 1:611 31ST AVE SW
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3723
Practice Address - Country:US
Practice Address - Phone:253-848-5951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.61492017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant