Basic Information
Provider Information | |||||||||
NPI: | 1396737706 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLL | ||||||||
FirstName: | VICKIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 GAGE BLVD | ||||||||
Address2: | SUITE 203 | ||||||||
City: | RICHLAND | ||||||||
State: | WA | ||||||||
PostalCode: | 993528650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099423627 | ||||||||
FaxNumber: | 5099422268 | ||||||||
Practice Location | |||||||||
Address1: | 4804 W CLEARWATER AVE | ||||||||
Address2: |   | ||||||||
City: | KENNEWICK | ||||||||
State: | WA | ||||||||
PostalCode: | 993362119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099422355 | ||||||||
FaxNumber: | 5092221289 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/22/2005 | ||||||||
LastUpdateDate: | 01/04/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA338 | ID | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA1392 | NV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA60168389 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 000010152179 | 01 | ID | BLUE SHIELD-DOWNEY | OTHER | 000010161109 | 01 | ID | BLUE SHIELD MCCAMMON | OTHER | 1396737706 | 05 | NV |   | MEDICAID | PAND8 | 01 | ID | BLUE CROSS-AM FALLS | OTHER | PANE5 | 01 | ID | BLUE CROSS-DOWNEY | OTHER | 000010152180 | 01 | ID | BLUE SHIELD-LAVA | OTHER | 2054118 | 05 | WA |   | MEDICAID | 000010152181 | 01 | ID | BLUE SHIELD-POCATELLO | OTHER | 000010152182 | 01 | ID | BLUE SHIELD-AM FALLS | OTHER | PANH9 | 01 | ID | BLUE CROSS-POCATELLO | OTHER | HB721Z | 01 | NV | MEDICARE PTAN | OTHER | PAE62 | 01 | ID | BLUE CROSS-MCCAMMON | OTHER | 807226500 | 05 | ID |   | MEDICAID | PANF3 | 01 | ID | BLUE CROSS-ABERDEEN | OTHER | PANG1 | 01 | ID | BLUE CROSS-LAVA | OTHER |