1396737706 NPI number — VICKIE BOLL PA-C

Table of content: VICKIE BOLL PA-C (NPI 1396737706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396737706 NPI number — VICKIE BOLL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLL
Provider First Name:
VICKIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396737706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 GAGE BLVD
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99352-8650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-942-3627
Provider Business Mailing Address Fax Number:
509-942-2268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4804 W CLEARWATER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-942-2355
Provider Business Practice Location Address Fax Number:
509-222-1289
Provider Enumeration Date:
08/22/2005

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: 363A00000X , with the licence number:  PA338 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA1392 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA60168389 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010152179 . This is a "BLUE SHIELD-DOWNEY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010161109 . This is a "BLUE SHIELD MCCAMMON" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1396737706 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAND8 . This is a "BLUE CROSS-AM FALLS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PANE5 . This is a "BLUE CROSS-DOWNEY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010152180 . This is a "BLUE SHIELD-LAVA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 2054118 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010152181 . This is a "BLUE SHIELD-POCATELLO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010152182 . This is a "BLUE SHIELD-AM FALLS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PANH9 . This is a "BLUE CROSS-POCATELLO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: HB721Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: PAE62 . This is a "BLUE CROSS-MCCAMMON" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 807226500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: PANF3 . This is a "BLUE CROSS-ABERDEEN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PANG1 . This is a "BLUE CROSS-LAVA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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