Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | RN233677 | GA |
NPI | 1003470402 |
---|---|
Provider Name | Mitchell Boles |
First Address | Newnan, GA 30265-2404 |
Second Address | Newnan, GA 30265-2404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2019 |
Last Update Date | 01/05/2019 |