Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 2008017225 | MO |
Y | 208600000X | Surgeon | 2008017225 | MO |
NPI | 1013178946 |
---|---|
Provider Name | Olivia Louise Bolles |
First Address | Columbia, MO 65212-0001 |
Second Address | Columbia, MO 65212-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2008 |
Last Update Date | 23/06/2008 |