Basic Information
| Provider Information | |||||||||
| NPI: | 1447676788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLES | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7210 VILLAGE MEDICAL CIR STE 110 | ||||||||
| Address2: | |||||||||
| City: | CLEMMONS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270128029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368932400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2014 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-04882 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.