1467613109 NPI number — AMBER LOUANN BOLYARD CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467613109 NPI number — AMBER LOUANN BOLYARD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLYARD
Provider First Name:
AMBER
Provider Middle Name:
LOUANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLMES
Provider Other First Name:
AMBER
Provider Other Middle Name:
LOUANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467613109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7703 FLOYD CURL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-358-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 S WALDRON RD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-2584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-785-2555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R71508 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP126085 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: CTP000070 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: C02707 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00628610 . This is a "RR MEDICARE GROUP CG8899" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 171992001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340737101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00872567 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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