Basic Information
| Provider Information | |||||||||
| NPI: | 1184213555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOULOM | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 UNIVERSITY BAY DR APT 315 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537052268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693485497 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3400 DEERFIELD DR | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535463557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083143600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2021 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5192-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.