Basic Information
| Provider Information | |||||||||
| NPI: | 1265046403 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLER | ||||||||
| FirstName: | LANDIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13618 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731131618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057153610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9600 BROADWAY EXT STE B103 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731147408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057153610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2020 | ||||||||
| LastUpdateDate: | 09/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 108944 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.