Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | OS010395L | PA |
N | 207VX0000X | Obstetrician | OS010395L | PA |
NPI | 1073516944 |
---|---|
Provider Name | Mr. John N. Boll JR. |
First Address | Williamsport, PA 17701-1900 |
Second Address | Williamsport, PA 17701-3100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2005 |
Last Update Date | 16/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1026698040001 | (05) | PA |
64052707 | (05) | KY |
H62432 | (02) |