Basic Information
Provider Information | |||||||||
NPI: | 1477817013 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLIVAR | ||||||||
FirstName: | BREANNA | ||||||||
MiddleName: | KEENAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 119 HENDERSONVILLE RD | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288032868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287715000 | ||||||||
FaxNumber: | 8282574750 | ||||||||
Practice Location | |||||||||
Address1: | 119 HENDERSONVILLE RD | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288032868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8287715500 | ||||||||
FaxNumber: | 8282574750 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2012 | ||||||||
LastUpdateDate: | 06/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 2014-02009 | NC | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207VG0400X | 2014-02009 | NC | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X | 2014-02009 | NC | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | NCT347A | 01 | NC | PTAN | OTHER | 1477817013 | 05 | NC |   | MEDICAID |