Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service | 0057466 | OK |
NPI | 1225413552 |
---|---|
Provider Name | Thomas Boley |
First Address | Muskogee, OK 74401-4431 |
Second Address | Muskogee, OK 74401-4431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2015 |
Last Update Date | 28/07/2015 |