Basic Information
| Provider Information | |||||||||
| NPI: | 1124062310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYLE | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3011 | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827173011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076882690 | ||||||||
| FaxNumber: | 3076881420 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S BURMA AVE | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827163426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076881000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 5772A | WY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 5772A | WY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 5772A | WY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 120624900 | 05 | WY | MEDICAID |