Provider Demographics
NPI:1659017853
Name:BOSTIC, ANGELA M (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5069
Mailing Address - Country:US
Mailing Address - Phone:575-532-4432
Mailing Address - Fax:
Practice Address - Street 1:5700 E HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-9110
Practice Address - Country:US
Practice Address - Phone:520-263-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100801367500000X
AZ312050367500000X
NM65512367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered