Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 309573 | NY |
N | 363LA2200X | Nurse Practitioner - Adult Health | 309573 | NY |
NPI | 1013538461 |
---|---|
Provider Name | Gordon Bolles |
First Address | Williamsville, NY 14221-8235 |
Second Address | Buffalo, NY 14203-1126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2020 |
Last Update Date | 21/01/2021 |