Basic Information
Provider Information
NPI: 1760443634
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BOYLE
FirstName: EVELYN
MiddleName: MARY
NamePrefix: DR.
NameSuffix:  
Credential: MD., FAAP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 150 TEJAS PL
Address2: PO BOX 430
City: NIPOMO
State: CA
PostalCode: 934449123
CountryCode: US
TelephoneNumber: 8059293211
FaxNumber: 8059296440
Practice Location
Address1: 336 S HALCYON RD
Address2:  
City: ARROYO GRANDE
State: CA
PostalCode: 934203818
CountryCode: US
TelephoneNumber: 8054813658
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/30/2006
LastUpdateDate: 02/15/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X34614AZN Allopathic & Osteopathic PhysiciansPediatrics 
208000000XA84291CAY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
T-6456005SC MEDICAID
370-01830601SCRAILROADOTHER


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