Basic Information
| Provider Information | |||||||||
| NPI: | 1497824379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLYOG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 W UTOPIA RD | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022146148 | ||||||||
| FaxNumber: | 6022146149 | ||||||||
| Practice Location | |||||||||
| Address1: | 6206 W. BELL ROAD | ||||||||
| Address2: | #5 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023755440 | ||||||||
| FaxNumber: | 6023755510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN017541 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 482538 | 05 | AZ | MEDICAID |