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NPI Code Detail

MEDICARE: MRS. ANITA BOULOM PA-C

MEDICARE: MRS. ANITA BOULOM PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant5192-23WI

General Provider Information

NPI Number : 1184213555
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ANITA BOULOM PA-C
Provider Business Mailing Address
First Line : 700 UNIVERSITY BAY DR APT 315
Second Line :
City : MADISON
State : WI
Zip : 53705-2268
Country : US
Telephone Number : 469-348-5497
Fax Number :
Provider Business Practice Location Address
First Line : 3400 DEERFIELD DR
Second Line :
City : JANESVILLE
State : WI
Zip : 53546-3557
Country : US
Telephone Number : 608-314-3600
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/11/2021
Last Update Date : 01/11/2021

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Directions to “ MRS. ANITA BOULOM PA-C” Practice Location

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